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Assessing Providers for Participation in Value-Based Care Contracts

How can payers assess healthcare providers when developing new value-based care contracts and other risk-based reimbursement opportunities?

Payers can assess new value-based care contracts with new evaluation tactics.

Source: Thinkstock

By Thomas Beaton

- Creating strong networks of high-quality healthcare providers can be a major challenge for any payer looking to expand its value-based care contract portfolio.

Providers aren’t the only ones accepting risk when entering into pay-for-performance arrangements since payers are also putting revenue and reputation on the line.  In order to ensure that a contracting arrangement can deliver exceptional patient experiences that will improve outcomes and inspire beneficiary loyalty, payers must choose their partners carefully.

How can payers evaluate potential participants in a value-based care arrangement, and what are some of the common challenges of navigating the process?

Improving credentialing processes for value-based care

As a first step, payers need to review their prospective providers’ credentials to ensure that they are able to meet their patient care obligations.

The credentialing process requires that providers submit their education, work history, and current value-based certifications related to their practice.

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Humana requires that providers use a service from the Council for Affordable Quality Care (CAQH), called CAQH Proview, to submit credentialing information. Humana providers also need to have a Drug Enforcement Agency and/or Controlled Dangerous Substances (CDS) certificate when submitting credentials.  

Aetna similarly requires providers to use the CAQH Proview platform and evaluates credentialing submissions based on NCQA quality standards.

Reforming a credentialing process to support value-based contracts may require considerable technology investments, according to CAQH’s Committee on Operating Rules for Information Exchange (CAQH CORE).

CAQH CORE suggested that technology investments can help both payers and providers improve the credentialing process as well as general data sharing practices needed in value-based care.

“By collaborating now, before proprietary systems and processes become entrenched in value-based payment operations, by reaching out to potential collaborators across the industry and by applying lessons learned through its success in the fee-for-service space, CAQH CORE hopes to energize an effort to ease value-based payment operational inefficiencies,” the organization said.

Building provider relationships and partnerships

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Payers should work alongside providers to create meaningful relationships that enhance the value-based contracting process and value-based adoption.

Establishing provider buy-in is key for developing value-based agreements such a bundled payment structure, according to Steve Anderson, Vice President of Contracting and Network Administration at BlueCross BlueShield of Michigan.

“Opening up the methodology, actually creating a model and sharing that with the provider community and offering up some of our capabilities helped with adoption,” Anderson said. “Generally trying to provide comfort or confidence that this [bundled payment] program, with our analytics and provider involvement, will yield success and positive outcomes.”

Kari Hedges, Senior Vice President, Commercial Markets & Enterprise Data Solutions at the BlueCross BlueShield Association found that scaling value-based care networks required payers to reach out to providers in order to understand provider needs and value-based capabilities.

“The way the healthcare market operates in Michigan might work differently in California and look different in Mississippi,” Hedges said.  “Understanding provider needs at the local level and how the provider community is organized helped us elevate value-based programs to a national level.”

Educating providers about contracting provisions

READ MORE: How Payers Can Effectively Scale Value-Based Care Networks

Payers will want providers that are familiar with value-based contract details to make sure only qualified providers are applying for value-based contracts.

Payers could help providers understand the components of provider contracts and gauge if providers are ready to operate in a value-based care network.

Unilateral contract amendments allow a payer to change reimbursement rates, network participation, and performance requirements within a set period, usually between 30-90 days. Unilateral agreements ensure payers can reassess quality performance quality as needed, but could disincentivize providers if they lack the capabilities to update operations.  

Providers should also be aware of network requirements to ensure they can participate in the appropriate care networks. Payers may use specific provider specialist groups for certain value-based networks and could limit other providers from network participation.

Healthcare payers may have a better value-based contracting experience if they find providers that have strong patient attribution and data-sharing capabilities.

Providers willing to participate in innovative networks need to ensure they can reliably analyze and measure performance. Provider organizations with a track record of success with data analytics tend to be more ready for value-based care.

Payers could help providers initially develop needed data analytics infrastructure to enhance patient attribution and engage in data sharing during the early stages of a value-based contract.

Value-based care adoption is climbing at a steady pace in the healthcare industry. Finding the best ways to implement value-based contracts may help payers create long-term success in improving care quality while lowering costs.


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