Provider Network Management & Contracting

A group comes back with a counter: a bump on the physician fee schedule, a different case rate on the procedures they do most, a per diem where you had a percent of charges, and a request to drop the lesser-of language. Before anyone answers, you have to know what that actually costs — not against the schedule in the abstract, but against the claims those providers actually sent you. So you pull the utilization, reprice it under the proposed terms, reprice it under the current ones, and the difference is the number. The complications are the whole job. Mix shifts. Care moves from one site of service to another. The codes the group bills most are not the codes the negotiation focused on. The carve-outs and the outlier language behave differently at volume, and a rate that looks flat in aggregate is a large increase on the one service line driving your medical spend. Then someone asks what happens if they walk, and now you are pricing where those members would have to go instead.

The directory is the thing members actually use, and it is wrong in ways that are hard to see from the inside. A physician retired and nobody told you. A group moved one of its three offices and the record still lists all three. A specialist closed her panel and is still showing as accepting new patients. The same clinician appears four times because four roster files spelled the practice name four different ways. You work rosters that arrive in whatever format the group happens to send, chase attestations from practices with no particular incentive to answer, and take the call from a member who drove across town to a suite where nobody has heard of the doctor. Underneath all of it is an obligation you cannot hand off: the directory is a regulated, member-facing document, the plan owns whether it is right, and a member who relied on it and got billed as though they had gone out of network has a protection you have to honor.

Adequacy is a filing, and it is also a fact, and the two can come apart. The filing asks whether members in each county can reach the required provider and facility types within the standards that apply to that line of business — a drive time, a distance, a minimum count, and increasingly how long it takes to actually get an appointment. So you assemble the network file, run it against the criteria, and find the gaps: a county short one cardiology location, a specialty where every provider you counted sits at the same address, a rural area that passes on paper because of a clinician who is contracted but not really available. Then you decide what to do about each one — recruit, extend an existing contract, or file for an exception and explain why the standard cannot be met there. Meanwhile the network moves underneath you. A group terminates, a hospital closes a service line, and the county that passed last quarter does not pass now.