A rural health network or community health network is a local, facility-based, preferred provider network that is used to provide a platform for direct-to-employer contracting and deployment of locally directed narrow networks with the various carriers. As the Affordable Care Act makes self-funding an attractive option and consequent explosion of carrier-developed narrow network plans, more health systems across the country are developing their own network options for both business development and ‘revenue stream protection’ purposes. Creating a strategy, infrastructure, and execution of a Community Health Network that best-suits your community is where we come in.
SHP’s involvement in the development can be as follows:
- Overall strategy development
- Provider solicitation
- Network infrastructure development: From developing provider demographic data base to acting as a conduit to share payer issues and resolve claims issues
- Network contracting: Modeling, language review and negotiation, and rate negotiation
However, before moving forward with such a strategy, the operations and network management capabilities must be thoroughly assessed. Key questions to ask that SHP can assess as well as implement and manage:
- Is there a provider database in place to maintain required demographic information?
- Are proper credentialing policies and procedures in place?
- Are there sufficient reporting capabilities to supply monthly downloads to third-party administrators as required?
- Do claims resolution capabilities, skill sets, and process exist?
- Is there a help desk function for network member questions and issues?
First, we look at how we can assist in determining market uses for such a strategy. Feasibility and local conditions for:
- Direct agreements with large employers
- Carrier agreements for fully insured products
- Health exchange products
- Medicaid Care Management Organization products
While assessing such external conditions, we evaluate internal feasibility as well:
- Evaluate CIN market strategy in line with overall growth strategy of Health System
- Determine other health plan ancillary relationships necessary to effective reach market with single stop approach
- Third party administrator(s)
- Disease management/high cost case management
- Stop loss carriers
We then move forward to contract execution:
- Contract with payers to deploy relevant market products
- Negotiate agreements as appropriate with selected payers (both direct and carrier agreements)
- Model rates to support negotiations, for both hospital and physicians
Developing a Community oriented network strategy is a very smart, financially sound, and patient focused initiative. Going down the due diligence path will force your organization to review internal processes that will only benefit all involved. It’s certainly a worthwhile endeavor and one SHP is prepared to assist.