A health plan's most valuable resource is its provider network, but many organizations struggle to recruit and retain providers. This is particularly true for Medicaid managed care plans, for which historically low reimbursement rates have made recruiting a challenge, particularly for specialist physicians. To identify solutions, the Association for Community Affiliated Plans (ACAP) conducted a survey and four in-depth case studies of its member plans. The plans stressed the importance of two complementary approaches: sustaining relationships with providers through regular and meaningful communications and using technology to facilitate process improvement. Specifically, plans experienced the greatest success in the following areas: 1) payment practices, incentives, and financial assistance; 2) utilization management; 3) communications and provider outreach; 4) simplifying administrative burdens; and 5) enabling services.
Type of Innovation: Improving Access in Health Plans
Organization: Association for Community Affiliated Plans
Dates of Development: 2004–05
T arget Populations: Medicaid administrators
The Issue: A health plan's most valuable resource is its provider network, but many organizations struggle to recruit and retain providers. This is particularly true in Medicaid managed care, where historically low reimbursement rates have made recruiting a challenge, particularly for specialist physicians. Because Medicaid enrollees have higher rates of chronic illness and disabilities than enrollees of private plans, stable access to specialty services for these patients is crucial.
The Intervention: To identify solutions to recruiting and retaining providers, the Association for Community Affiliated Plans (ACAP) conducted a study of its member plans, selecting four plans for in-depth case studies. The plans stressed the importance of two complementary approaches: sustaining relationships with providers through regular and meaningful communications and using technology to facilitate process improvement. Specifically, the plans experienced the greatest success in the following five areas:
- Payment practice and incentives. Although best-performing Medicaid plans have limited ability to improve provider reimbursements, they try to pay promptly. Most efforts to improve claims turnaround time concentrated on frontline processes, departmental reorganizations, new technologies, and financial incentives. Some plans offer financial incentives aligned with high-quality care.
- Utilization management.Plans sought to address providers' frustrations with the referral and authorization process by improving utilization management and introducing technology to facilitate authorizations and referrals.
- Communications and provider outreach.Plans cultivate relationships with their providers through in-person meetings and regular written communications about changes to administrative procedures, clinical breakthroughs, quality measures, and legal updates.
- Simplifying administrative burdens.Many plans have simplified eligibility and credentialing processes, and a few have taken steps to simplify the process for health care encounter data submission.
- Enabling services.Some plans help patients keep their appointments by offering transportation, child care, interpreter services, and cell phones to patients who lack telephone services.
The full report and recommendations are under Related Resources, at right.
For more information: Contact Karen L. Brodsky, M.H.S., independent health care consultant, at [email protected].