Empowering Providers, Solving Payer Network Adequacy

Summary

The Tribunus Health three-step approach—Data, Differentiation, and Diligence—empowers healthcare providers to demonstrate their value while addressing payer network adequacy challenges. Leveraging the well-respected Get/Who/To/By framework, we create targeted strategies that showcase provider strengths, fill critical network gaps and drive meaningful outcomes. This method ensures fair reimbursement for providers and delivers payers enhanced network adequacy, quality metrics and cost savings.

Introduction

In today’s healthcare landscape, providers face challenges in demonstrating their value to payers and securing fair reimbursement. Simultaneously, many payers struggle with network adequacy issues. At Tribunus Health, we’ve developed an approach that addresses both challenges.

Let’s explore how this strategy  transforms provider advocacy and payer networks.

The Tribunus Health Method: Data, Differentiation, Diligence

Our three-step approach empowers providers and offers solutions to payers:

1. Data: We gather and analyze comprehensive data on provider performance, market dynamics, and potential payer network gaps.
2. Differentiation: Using the time-tested Get/Who/To/By framework, we help our provider clients stand out to payers.
3. Diligence: We leverage our insights to negotiate fair reimbursement and advocate for appropriate network inclusion.

Let’s dive deeper into the Differentiation phase, where our Get/Who/To/By framework shines.

The Power of Get/Who/To/By in Provider Advocacy

We tailor this framework specifically for healthcare provider advocacy:

• Get: Identifies the target audience (specific payers)
• Who: Specifies the exact persona within that audience
• To: Defines the desired action or change in behavior
• By: Outlines the means or reason for achieving the desired action

This framework allows us to create laser-focused strategies that resonate with payer decision-makers and drive meaningful change for our provider clients.

The Tribunus Health Method in Action

Step 1: Data

We begin by collecting and analyzing crucial data:

1. Comprehensive analysis of the provider’s performance metrics and outcomes
2. Identification of payer network gaps in the provider’s area of expertise or location
3. Assessment of patient outcomes and satisfaction rates
4. Market analysis to identify the provider’s unique strengths and differentiators

Step 2: Differentiation

Using the Get/Who/To/By framework, we develop a tailored strategy to set our provider client apart:

1. Get: Payers 
2. Who: Have network adequacy concerns and pain points including regulatory pressure, member complaints, and gaps in specialty care
3. To: Recognize the significant value of including our provider client in their network
4. By:
   • Demonstrating how the provider fills critical network gaps
   • Showcasing the provider’s superior patient outcomes and satisfaction rates
   • Illustrating potential cost savings through efficient care delivery
   • Highlighting the provider’s unique capabilities or technologies

Step 3: Diligence

Armed with data-backed insights and a differentiated position, we then:

• Negotiate fair reimbursement rates that reflect the provider’s true value
• Advocate for appropriate network inclusion, ensuring win-win scenarios
• Continuously monitor performance to maintain and strengthen the provider’s position
• Provide ongoing support as market conditions and payer needs evolve

The ROI for Payers: Why Including Our Provider Clients Matters

By including our provider clients in their networks, payers can expect:

1. Improved Network Adequacy: Fill critical gaps in specialty care or underserved areas 
2. Enhanced Quality Metrics: Benefit from our clients’ superior patient outcomes
3. Increased Member Satisfaction: Provide access to highly-rated, efficient providers
4. Cost Savings: Reduce out-of-network claims and benefit from our clients’ efficient care models
5. Competitive Advantage: Offer members access to distinguished providers in key specialties

Case Study: The Win-Win in Action

The Back Story

As a new provider in a market dominated by larger national providers, our client was looking to expand across the southeast. After a year of pursuing payers on their own and being met with nothing but resistance, our client reached out to us for help. 

The Plan

The Tribunus Health team immediately got to work identifying market gaps with payers and other major players, carving out a specialty niche for our client. We presented payers with irrefutable proof that our client was providing necessary at-home services, as evidenced by the abundance of data on in-hospital costs from delays in care due to payers and providers denying at-home treatments.

The Win 

Our hospital cost analysis, combined with our deep market knowledge, allowed the Tribunus Health team to formulate proposals for national network participation, resulting in three new contract opportunities with major payers. We also invested in our clients’ success by educating them on specialty drug pricing as they began to provide specialty products at home.

Conclusion: Transforming Provider Advocacy and Payer Networks

The Tribunus Health Method offers a data-driven, differentiated, and diligent approach to provider advocacy that simultaneously solves payers’ network adequacy challenges. By leveraging the Get/Who/To/By framework within our comprehensive method, we help providers demonstrate their true value and help payers build robust, high-quality networks.

Are you a healthcare provider looking to secure fair reimbursement and expand your payer network relationships? Contact Tribunus Health today for a personalized analysis and see the power of our method in action.