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Network Adequacy

A network adequacy solution that identifies gaps in health insurance networks and suggests additional providers to meet CMS requirements.

Challenge

CMS requires every Medicare Advantage plan to maintain an adequate network, ensuring that 90% of their members have access to care from a defined list of specialty provider types based on time and distance. States also may require their own network adequacy standards based on provider types, time and distance parameters, for commercial Medicaid insurers.  The penalties for not having an adequate network can include financial sanctions and affect the insurer’s reputation.

Contact Us

Unlock the power of precision with a complimentary data analysis or list match.

HealthLink Dimensions:
Phone: 404.250.3900
Email: info@healthlinkdimensions.com

Solution

HealthLink Dimensions’ Network Adequacy pre-loads provider information from CMS, then analyzes this data to identify potential adequacy issues for time, distance, and other mandatory categories. Network Adequacy then filters for false positives and provides suggestions for providers that fill any remaining gaps using our industry-leading multi-source provider data assets.

Feature

Nationwide provider list with accurate and up to date provider addresses.

Benefit

Ability to find all providers of a specific specialty type within specified distance radius of a zip code or county population center. This helps payers find the providers that would be eligible to fill gaps and filter by those that already accept Medicare and group them by affiliation to clinics.

Feature

Geocoding providers to members, identifying where the network is sufficient and where there are gaps by provider type and geography.

Benefit

CMS currently does not offer a tool to run “what if” scenarios for health plans that are in initial stages of building a new product or expanding to a new county or service area. Insurers need the ability to test networks prior to submitting a formal application. This feature allows health plans to approximate government algorithms, get a good idea of their network adequacy and identify any gaps that need to be filled.

Feature

Monitors provider networks and alerts provider contracting teams and compliance officers when a gap is created by changes in provider status or address.

Benefit

Gives payers up-to-date alerts when a provider moves or stops practicing in a region, creating a network gap. This enables payers to proactively fill that gap with new providers and maintain compliance. This is particularly important close to the audit period when networks will be tested. At that point, time is short for payers to assess adequacy through official channels and fill any newly identified gaps.

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