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Provider Networks

Provider Network Management

The process used to help health plan payers and health systems maintain and organize data from the provider for the purpose of building, managing and optimizing the provider network to meet the needs of the recipients, provider(s) and health system. Successful provider network management consists of provider network development, provider network performance, provider network reimbursement, provider network operations.

Provider Network Development

PHC specializes in provider network development and complex contracting. We have extensive experience with various types of network builds throughout the United States. Local, regional, state and national clients benefit from our support and expertise in the following type builds:

  • ACOs

  • Behavioral Health

  • Commercial Insurance

  • DCEs

  • Dental

  • Health Exchange

  • Long Term Services & Supports (LTSS)

  • Home & Community Based Services (HCBS)

  • Medicare Advantage (MA)

  • Medicaid

PHC has delivered solutions and provided support for some of the nation’s top insurers along with regional health plans, special-needs organizations, specialty insurers, health systems and multi-specialty provider groups.

Provider Network Analysis and Strategy

Network optimization is critical to long term success. The PHC team will:

  • Identify critical providers, their market share & clinical reputation for each geographic region.

  • Determine provider relationships (health systems, ACOs, key physician groups, etc.).

  • Determine regulatory and plan requirements for network adequacy.

  • Establish network configuration goals.

  • Produce quality results which yields valid provider records for publication

Payer and Provider Network Reimbursement

Provider reimbursement is as diverse as health plans and providers are. Our team does not believe in a one method fits all approach. We support clients with a variety of provider reimbursement strategies included but not limited to fee-for-service percentage of billed charges and value-based contracting strategies. We work with clients to determine and produce the reimbursement methodology that will be optimal for provider, client and reduce impact on the patient. As needed, we offer support to help the client implement and/or train their team on the reimbursement models.

Provider Network Operations

Every successful provider network is steeped in proper, complete and efficient operations. The use of current and accurate data and employing proper operations will position the client to be successful and compliant. PHC offers the following:

  • Provider Network Assessment

  • Provider Training needs

  • Provider Reporting and Status Checkpoints

  • Provider data, directory and credentialing accuracy

  • Provider Contracting Data Accuracy and Process Flow

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