Healthy decisions Featured

8:00pm EDT March 26, 2009

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