Medicare Advantage: Show your value

Q. What are some strategies for providers to become part of narrow payer networks? 

A. Over the past decade, provider networks for payers have become increasingly difficult for providers to join or remain a part of. Providers face several challenges in becoming part of these networks, including the need to demonstrate their value to payers and navigate complex contracting processes. 

Providers aim to serve as many patients as possible, which requires being a trusted and convenient solution. However, being attractive to patients and referral sources is not enough; providers must also appeal to payers to be included in their networks. This is crucial because patients with insurance prefer providers within their network to minimize out-of-pocket expenses. 

The process of contracting with payers is challenging. Gone are the days when payers would offer contracts to any interested provider. Providers must now show payers why they should be added to the network and what value they bring. This involves conveying their value proposition effectively to avoid being seen as an additional administrative burden. 

Payers are increasingly operating with smaller, narrower networks, sometimes canceling contracts to reduce administrative burdens or remove underperforming providers. Providers focusing solely on Medicare and Medicaid contracts may find this insufficient, as Medicare Advantage plans and Medicaid Managed Care Organizations (MCOs) require separate contracts. 

To address these challenges, providers must know their worth, understand their costs and ensure fair compensation. They should articulate their value clearly to both payers and intermediary companies offering network solutions. Efficiency and the ability to do more with less are essential, and providers must continuously demonstrate their value to sustain and grow their business. 

In summary, providers must navigate complex contracting processes, demonstrate their value to payers and adapt to narrower networks to effectively serve patients and grow their business. 

Kim Cuce is director of business optimization for VGM Group. Reach her at kim.cuce@vgm.com.