Healthcare: network development on behalf of a provider sponsored managed care organization

Challenge:

The organization needed to transform its delivery model from a provider of health care services to a provider sponsored health plan and was approved to participate in the Fully Integrated Dual Advantage (FIDA) demonstration program.  However, they did not have a comprehensive provider network to support their application.  As a new and relatively unknown entity, they turned to us for our market expertise and provider relationships.  We worked with the client’s leadership team to develop a network contracting strategy.

Solution:

Mazars assembled an experienced project team to deliver a viable network to meet the approval of CMS and the New York State Department of Health by implementing the following:

• Developed provider recruitment collaterals
• Identified preferred provider targets by specialty type to achieve network adequacy standards
• Established rate and language parameters to adhere to financial projections
• Negotiated agreements with health systems, hospitals, large physician groups (including IPAs and Faculty Practices), ancillary providers and individual physicians
• Implemented a vendor identification and selection process to contract for behavioral health services
• Electronically organized and tracked all executed agreements and credentialing documents
• Monitored network adequacy throughout the engagement utilizing Quest Analytics and proprietary tracking reports to ensure regulatory compliance
• Produced required submission reports in compliance with federal and state regulatory standards
• Utilized data management and reporting tools to collect, organize and transmit information back to the client

Results:

We delivered a completed FIDA network within the client’s required deadline leading to:

• Achievement of regulatory compliance in nine (9) counties of downstate New York
• Maintained network reimbursement rates within client established parameters
• Established relationships with key health systems in all targeted counties