Health Care
Healthy decisions
How to choose the right provider network
By Meredyth McKenzie
Smart Business Detroit | April 2009
Mike GrodusAssociate vice president of network strategy
and provider performance
Priority Health
Choosing the right provider network
for your company health plan can
be a tough task. You want to make
sure that it is the right size, has good coverage and a good variety of products,
includes the best doctors and hospitals in
your area, and is the most accessible for
you and your employees.
“Selecting a health plan for your employees includes due diligence on your part to
ensure the plan’s network of physicians,
hospitals and other providers will meet
your needs,” says Mike Grodus, associate
vice president of network strategy and
provider performance for Priority Health.
“Asking a few questions upfront can help
determine not just the size but the quality
of the network, as well.”
Smart Business spoke with Grodus
about how to choose the right provider
network, the advantages of a smaller network over a larger one and how to learn
more about the quality of physicians in
your network.
How do you know the quality of the
providers in the network?
Each health plan has its own process for
verifying the qualifications of a provider.
Priority Health has an extensive credentialing process to confirm a provider’s
expertise before he or she is even added
to our network. The credentialing process
includes primary source verification to
assure that the provider is licensed and
that there are no sanctions on the license.
There is also verification that the
providers have no exclusions for federal
programs. Malpractice history is reviewed
and board certification is validated.
The credentialing process assures that
all guidelines required by the National
Committee for Quality Assurance
(NCQA) are met. Once that happens, the
provider’s information is presented to the
Priority Health Credentialing Committee
for approval.
What kind of research should you do
upfront?
Make sure the network includes major
hospitals, adequate primary care physicians and specialist coverage, and check
to see which counties are in the service
area. Look at the quality performance of a
network and how well the plan works
with your physicians to achieve the best
quality.
Review the quality rating of the plan as
measured by the NCQA. This will indicate
the health plan’s focus and commitment
to quality and to having a high-performing
network.
If you visit the plan’s Web site, there
should be information about its network,
what quality programs they have, how
physicians are measured and a directory
of participating providers.
How can you find the best providers within a
network?
Quality ratings, or provider report
cards, are becoming more common.
Priority Health has apple ratings. These
ratings measure a physician on quality,
which is composed of 12 preventive
health and disease management measures. The ratings are updated on an annual basis. These ratings are not given to a provider until they have been in our network long enough to gather sufficient
data.
What are the advantages of having a smaller network over a larger network?
You may have a network that might not
be the largest, but 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 with which
providers are added to a network.
Certainly, it can’t be too small, so you still
have to have a sufficient number of
physicians and geographical coverage
that would allow for servicing your
employees.
What are the benefits of choosing the right
health network?
Health care is a personal issue. If you
have a number of employees who aren’t
happy with the performance of the network — their physician may not be in or
there aren’t enough providers to choose
from near them — this could lead to
employee dissatisfaction. That’s certainly
an area where you don’t want any
dissatisfaction; you want to make dealing
with the network a good experience for
them. Make sure that you’re with the
right organization that has the right doctors, the proper customer service and
quality providers that take care of your
employees.
All of this helps create a healthier work
force where employee absenteeism is
minimized, employee productivity improves and, if you have a self-funded
product, it keeps your health care costs
down.
MIKE GRODUS is associate vice president of network strategy and provider performance for Priority Health. Reach him at (248) 324-2825 or mike.grodus@priorityhealth.com.
