Why The Time Is Now For Building Medicare Advantage Networks

For healthcare payer organizations, Medicare Advantage (MA) represents one of the most dynamic and competitive opportunities in the marketplace. With the number of Medicare beneficiaries growing, MA enrollment continues to move sharply upward. As of 2023, nearly 32 million people were enrolled in MA and related plans.

 Building MA networks is a must. But deadlines and complexity can stand in the way.

 Medicare Advantage Networks: Opportunities and Obstacles

 Ongoing interest in MA represents significant potential revenue benefits for payers, but the process is subject to obstacles and time pressures. Payer organizations who recognize the crucial need for building MA networks face headwinds including:

• Changing submission deadlines. Submissions for MA networks, although subject to change, must be made by February; until two years ago, the deadline was June. This radically shifts timelines and could catch many payers looking to make up for lost time.
• New requirements. New provider types are now required for MA, including behavioral health providers.
• Stringent submissions standards. Something as small as an errant decimal in data can cause submission failure.
• Lack of internal resources. Many organizations lack staffing and expertise for substantial MA network building or expansion or have resources already fully committed to existing provider networks.
• Manual processes and limited data insights. Many organizations are reliant on outdated workflows and processes that hinder expanding their provider networks.
• Recruitment obstacles. Without deep, reliable data resources, payers may struggle to identify and attract the right mix of providers to meet a health plan’s time and distance guidelines, provider ratio requirements, and appointment wait time standards. Additionally, there is increasing focus on contracting providers who offer after-hour care, 24/7 support services, and above-satisfactory patient outcome and access metrics.
• Compliance and visibility. Changing regulations can make network compliance overwhelming, resulting in costly errors and delays that can rapidly impact healthcare payers’ bottom line.

Building Optimal MA Networks: Acting with a Sense of Urgency

Changing requirements and deadlines further complicate the already challenging task of expanding Medicare Advantage networks for payer organizations.

But failure isn’t really an option, not for healthcare industry leaders tasked with leveraging the undeniable opportunities that MA represents. Indeed, leadership with clear vision knows that robust MA networks, established and expanded with sound provider network management, can be the dividing line between organizational success and fiscal crisis.

So how to get there? Leveraging the considerable benefits of automation and technology is the crucial foundation to building robust Medicare Advantage networks. The primary benefits:

1. Provider network vetting and data-driven matching.
   • Automated provider network management solutions for MA drive reductions in necessary time and resources for healthcare payer organizations. Leveraging clean, accurate existing data from existing provider networks means payers don’t have to start from scratch.
   • Data analytics from automated solutions identify the right providers for payers’ specific needs and target populations, bypassing manual processes that can stand in the way of building a robust network in a timely manner.
2. Streamlined workflows and a user-friendly platform.
   • Tasks such as provider outreach and contracting, along with vital ongoing provider network management measures, can attain great levels of accuracy and efficiency with automated technological solutions.
   • Real-time insights, transparency, and visibility lend up-to-the-moment understanding as MA networks are built, ideally with platforms that lend access and actionable data to users.
3. Automated credentialing and regulatory expertise.
   • Credentialing and compliance for MA provider networks require in-depth understanding of a web of requirements and regulations. Any error can result in lost time, revenue, and customer and provider satisfaction. Automated solutions streamline variables such as state-specific credentialing requirements that allows payers to expedite provider enrollment.
   • Support teams from automated provider network management solutions lend human expertise for staying up to date on all regulations and complexities of compliance, adding an extra level of confidence to MA network building.

Expanding and Building Medicare Advantage Networks the Right Way

There is little time to lose for healthcare payers looking to build or expand MA networks. Leaders and decision-makers who partner with the right technological solutions for their organizations find that the task can be a significant fiscal and organizational asset rather than an internal roadblock.

Today’s technology, leveraged the right way, with the right partners, delivers benefits such as scenario modeling to fine-tune a payer’s network strategy. Smart reporting allows visibility into progress in building and growth.

In the big picture, technological solutions mean healthcare payer teams are given the advantage of working with an intelligent line of sight rather than reactive response to overwhelming complexity. This means greater alignment and collaboration between teams and divisions, maximizing the skills and insights of all stakeholders, and greater success for all.