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The Five Pillars of a Provider Network Program

—January 01, 2015
The Five Pillars of a Provider Network Program

By Lee Haripko

A strong provider network program is critical to a property and casualty (P&C) insurers’ cost containment, benefit extension and customer retention strategies. Both in the workers’ compensation and auto casualty markets, one tremendous opportunity to retain customers and maintain a competitive edge comes from the lower claims costs associated with provider bills that fall into provider networks.

Positive customer satisfaction is a requirement for retaining customers and growing a business. The claims process is one of the best opportunities for P&C carriers to provide added value to their policyholders. For auto insurance carriers, using voluntary provider networks lowers the costs associated with claimrelated medical treatment and enables policyholders to receive additional, necessary, medical care since they will not reach their policy limits as quickly. This translates to customer benefit extension, which in turn can drive a better customer retention outcome.

In workers’ compensation, a reduction in claims cost is achieved through accessing a preferred provider organization to receive contracted discounts beyond state fee schedules and bill review reductions. By helping injured workers get healthy in a more cost effective way, workers’ compensation insurers’ can clearly show their concern for their customers in a fiscally responsible manner and lower their overall claims costs in order to remain competitive within the industry.

To execute an effective provider network program, it is helpful to examine the five key pillars of a successful program. Each pillar is a fundamental component of the program and together they form a strong, supportive foundation for success.

Pillar #1: Optimization

Optimization analysis is the evaluation of a network mosaic that drives the best possible yield. Partners in provider network management likely offer a wide array of networks — specialty networks, geographically focused networks, pharmacy networks, out-of-network negotiation services and specialty bill review. The key to maximizing the value of these various types of provider networks is the ability to analyze the best combination to fit a business. The hierarchy of the networks and cost containment solutions have a tremendous impact on penetration rates, customer benefit extension, and turnaround times.

Ongoing analysis utilizing rich data sets and technology-based optimization tools are critical to maximizing overall success of a provider network program. In addition, it is beneficial to analyze workflow to ensure that it maximizes the opportunity of using a provider network program and out-of-network solutions.

Pillar #2: Single-Source Management

There exist a broad array of provider networks, a number of which have differing merits. As a P&C carrier, managing those networks individually can be challenging and ineffective from both an efficiency and cost perspective. An effective partner should provide single-source management for all partners and their respective solutions. Partners should be able to create management programs that help to analyze and optimize networks based on workflow and bill analysis; handle any provider disputes expeditiously; and provide subject matter expertise in the areas of technology, compliance, and net results. A proactive approach to managing the provider network relationship is essential to gaining better insight into the program. The provider network management program should also have a workflow analysis component, since it is the combination of business rules, technology solutions and network yield that contribute to the success of the program.

Pillar #3: Technology

Technology plays an important role in any provider network program and drives adjuster workflow. A robust medical bill review software solution is a necessary element for the provider network program. Turnaround time is essential — most importantly, it provides the necessary time and quick content to support proper claim payment decisions; and maintains strong provider relationships to promote the most seamless outcomes for the claimant. The availability of pre-built technology bridges, including real-time bridges from the bill review solution to the provider network is essential to sending bills over to the providers for repricing. This integration between the software solution and the provider network increases both efficiency and the effectiveness of the program.

Pillar #4: Reporting

A person cannot improve on what cannot be measured. Reporting is another key element that provides valuable insight into the progress of the provider network program. Take for example personal financial portfolios — a person allocates dollars to specific investment vehicles, then monitors, rebalances, and reconfigures based on the results. A best-in-class provider network program should be following a similar model. However, customers of provider network programs are also responsible for achieving the best results for the organization and policyholders. Executivelevel reporting of programwide results is built from a reporting foundation of granularity, which should allow the customer to analyze results in the most detailed fashion. With a comprehensive reporting platform, the program can be evaluated and adjusted as needed.

Pillar #5: Integrated Workflow

Bill review system integration provides a great deal of transparency and control into provider network behavior and recommended repricing. The ability to review provider network reductions either before or after a triggering event, alongside the flexibility of setting automated flags, rules, and intelligent logic, creates the most seamless of provider network programs. Integrated workflow overlaps with several of the other pillars, enabling better reporting and speed to execution. It also allows a partner who understands the workflow to consult, advise and drive even greater results.

Provider network programs can deliver cost containment advantages and the opportunity to extend customer benefits. Though the provider network partner should carry the vast majority of program responsibilities, maximizing return on investment and optimizing outcomes is a joint effort.


Lee Haripko is senior manager of strategic partners at Mitchell International Auto Casualty Solutions.

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