Health plans have an opportunity to turn provider network management from a reactionary business function to an optimized organizational asset—one that supports enterprise growth, improves provider experience, and helps meet member needs. The timing is right, with positive industry trends that could support this shift and a growing need to track capability performance and maturation across provider enrollment, provider data management, directory management, and network development and performance.  

In this article, we highlight a maturity model of 5 core capabilities and key drivers of success that health plan executives can leverage to transform their provider network management operations. We also include insights executives at leading health plans shared during a recent roundtable on the topic—including persistent challenges to overcome and their experience with pursuing more strategic provider network management.

Emerging Trends Offer Opportunity, Even Amid Persistent Challenges

Several positive industry trends are creating greater opportunity for health plans to cultivate maturity in their provider network management, including:

  1. Growing recognition of the importance of managing the provider lifecycle as an end-to-end process (from recruitment to contracting and enrollment to ongoing provider data maintenance).

  2. Increasing understanding of the strategic value of high-quality provider data to drive network strategy and performance.

  3. Significant technology investments across multiple health plans to improve provider data management systems.  

However, leaders will have to tackle several ongoing challenges within provider network management. Leaders at the recent roundtable highlighted heavy reliance on manual data entry, inability to measure operational performance against basic cost and quality key performance indicators (KPIs), difficulties defining and realizing business cases for needed investments, limited movement on directory data accuracy, and even over-saturation of vendors with provider data management capabilities. One leader stated, “There are 100 different versions of what is most accurate.”  

While health plans often have many initiatives competing for the same funding pool, deprioritizing initiatives related to provider data management can impact revenue, provider relationships, and overall bottom-line performance. Leaders noted that funding for provider network management initiatives often becomes available only in a reactive way (e.g., if a software system needs to be retired, if a state regulator assigns a corrective action plan, or if there are significant claims payment issues). However, this historical reactive approach to provider network management is shifting to be more proactive as an increasing number of use cases beyond claims payment (e.g., network performance and growth strategy) require accurate provider data. As one leader stated, “There is a turning of the ship because of the increased demand for using provider data.”

Assess for Performance: 5 Core Capabilities of Provider Network Management Maturity

Health plans can enable proactive performance improvement by evaluating their provider network management capabilities against a maturity model. A model that resonated with the roundtable participants was our assessment framework, which benchmarks maturity against 5 core capabilities and their potential benefits:

  1. Operational effectiveness: Health plans with high-performing provider network management capabilities use automated KPI monitoring to measure unit costs, enrollment turn-around times, and reliance on manual data updates.  

  2. Data management and governance: Continuous improvement programs for data quality and a digital front door for providers are hallmark capabilities to drive a centralized provider data management strategy.

  3. Provider and member experience: Leveraging input from adequacy analyses, quality assessments, and provider and member feedback can shape network and product designs and fuel enterprise growth.

  4. Regulatory compliance: Maintaining laser focus on state and federal regulatory activity enables payers to anticipate new requirements and leverage them to enhance operations.  

  5. Technology enablement: Intentionally designed technology suites that fuel all an organization’s provider data needs can facilitate analytics-based automations and automatic contract and network loading.


While maturity in all 5 areas is the goal, an organization can be more mature in some components but lagging in others. For example, a plan that has invested in technology updates may still struggle to stay on top of regulatory activity. By evaluating against a maturity framework, provider network management leaders can identify which gaps are most impactful and where to prioritize continued investment toward the next level of performance. Health plan leaders rated their organizations as more mature in certain capabilities versus others and acknowledged that even as they may prioritize maturity in select capabilities, it’s hard to reach full maturity in those areas if they aren’t also making progress in the other capabilities.

Leaders also shared that some improvement initiatives can produce adverse effects, so health plans need to continually identify and implement innovative strategies. For example, a health plan may be focused on technology enablement, developing capabilities to automate provider data updates (which is key to reducing operating expenses). But immediate efficiency may be impacted by the high number of fallouts that require manual intervention. Auditing these new fallouts and assigning confidence levels to provider groups is a strategy that can increase automation levels.

4 Key Elements That Will Enable Success  

Sharing their own experiences, roundtable participants agreed with these 4 key takeaways that will drive success, no matter how mature a health plan is in its provider network management:

1. Take care building your business cases.  

Building a business case for improving provider data management can be a challenge. While proving a direct return on investment (ROI) or cost reduction can be complicated for these types of projects, some of the tangible benefits include the ability to grow and retain members, increase the accuracy of claims payments the first time, improve provider retention, and leverage data to advance strategic initiatives. Avoiding an unplanned audit or process failure should also be top of mind for the business.

One roundtable participant noted, “It is important not to underestimate how much a full project will cost just to make it easier to get initial funding.” Funding an “MVP” is only helpful if what comes out of that project truly delivers value as a stand-alone initiative. Defining and maintaining a strategic provider data roadmap can help project the real costs of new initiatives, making any additional budget requests expected. Including reporting capabilities to track milestones and benchmarks is imperative to initial success.

2. Build transparency into your operations.  

Provider network operations are complex, involve multiple internal and external stakeholders, and require highly integrated systems and teams to be successful. 

Building transparency to highlight where data problems exist and drive accountability is critical. Another leader stated, “There is a need to pull back the curtains and allow others to come on in.” With detailed reporting and performance dashboards, health plans can begin to pinpoint problem areas and prevent manageable issues from blooming into larger challenges.

3. Stay ahead of data requirements.  

Emerging data needs are top of mind for provider network management leaders. As one roundtable participant stated, to obtain these new data elements, “you have to get to the right person.” Leaders highlighted several factors contributing to these requirements:

  • Data needs to be standardized across the industry and within the individual health plans so all systems speak the same language. This will enable strategic reporting.  

  • Many providers working at urgent care centers or retail clinics are asking health plans to represent them differently in directories from their credentialed specialty.

  • There is a growing emphasis on collecting data related to health equity, sexual orientation, and gender identification (SOGI). Health plans must define the best way to collect data about whether a provider treats a population, identifies as a member of a population, or is certified in related treatments to help plan members identify providers from whom they might receive culturally sensitive and appropriate care.  

  • With the continued trend toward alternative payment models, health plans need to tie the right providers to the right contracts to appropriately manage performance, claims, and revenue.

4. Think outside the box when it comes to ensuring members have access to appointments.  

Even with the best data management, it is becoming increasingly difficult for members to make appointments with in-network providers in certain geographies and specialties. Another roundtable participant stated, “We have to lean on our provider relationships where we can to help with appointment availability.”  

Adding new providers to a health plan’s network can increase the number of available appointments, but in some geographies, the majority of available providers may already be in network for the plan. Health plans are building creative ways to secure appointments for their members into their provider network management strategy. For instance, some health plans are making an appointment on behalf of the member or building incentives into contracts to reserve a block of appointments for those plan members. While appointment availability challenges may point to a larger workforce shortage issue, plans should consider these and other strategic tactics, like offering telehealth, to ensure their members have access to care.  

Invest in Provider Network Management Maturity to Position for Growth

Health plans have an opportunity to proactively invest in provider network management to enable enterprise growth and meet member needs. To start, health plans should evaluate current capabilities against a maturity framework along the 5 dimensions noted above. This will allow them to understand performance within and across these areas, identify short- and long-term improvements, and design and implement targeted improvement initiatives that are structured and sequenced to meet their unique needs and goals. 

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