How can you be sure of the quality of providers in your network?
Each health plan has its own process for verifying the qualifications of a provider before he or she is added to a network. A credentialing process ensures that all guidelines required by NCQA are met and includes primary source verification to ensure that the provider is licensed and has no sanctions or exclusions for federal programs. Malpractice history is reviewed and board certification is also validated.
If everything is met, the provider’s information is then presented to the credentialing committee for approval.
Quality ratings, or provider report cards, are also becoming more common. These ratings measure a physician on quality. Ratings are updated annually. Providers are not rated until they have been in the network long enough to gather sufficient data.
Are there benefits to choosing a larger network over a smaller one?
You may have a network that might not be the largest, but it can be even more effective if the plan is fully engaged with physicians who have high quality ratings and scores. Some providers are better at applying managed care principles and are more engaged in a health plan’s programs, while others may not fully engage themselves in the program.
Sometimes it’s an advantage to be selective in which providers are added to a network. But the network can’t be too small, and you still need to have a sufficient number of physicians and geographical coverage to be able to service your employees. You can have a better product with good coverage and fully engaged physicians.
What questions should you ask a health plan about its network when you’re ready to solicit quotes?
Questions should include:
- What is the network’s geographical coverage?
- What is the adequacy and accessibility of network providers for employees?
- What products are offered?
- What is the health plan’s emphasis on quality, provider pricing discounts and employee healthy living programs?
The variety of products available is important as you try to best match health care coverage to your company’s health care needs.
Mike Grodus is associate vice president of network strategy and provider performance for Priority Health. Reach him at (248) 324-2825 or [email protected].
