Programme overview
Introduction:
Health insurance provider network management, covering network design, contracting and tariffs, is a 1-week course for provider network, contracting and provider relations units at insurers, third-party administrators and government payers, ending with a Provider Network Strategy and Contracting Plan for a case payer. Networks fail members and budgets when access gaps go unmeasured, price lists renew without benchmarking and contracts lack outlier and exit terms. Nominees already contract or monitor hospitals and clinics, and work through case studies on network maps, tariff files and contract drafts. CoreConcept Training Center delivers this provider network management course.
Course Objectives:
- Measure network adequacy using time-distance, provider-to-member ratio and appointment wait access standards and set targets to close the gaps found
- Select and tier hospitals, clinics and diagnostic centres using credentialing inputs, quality indicators and unit cost
- Benchmark provider price lists and negotiate tariffs, discounts and package rates against a prepared mandate and walk-away point
- Draft DRG, per-diem, outlier and stop-loss terms that keep inpatient spend predictable for the payer
- Run provider scorecards and contract audits and act on tariff variance and service failures
- Handle provider disputes, corrective action plans and terminations while protecting member access to care
Target Audience:
- Provider network development units that recruit hospitals, clinics and diagnostic centres into payer networks
- Provider contracting units that draft agreements, price lists and tariff schedules with providers
- Provider relations units that handle provider performance, queries, disputes and exits
- Network analytics units that measure access, unit cost and provider performance across the network
- Government payer purchasing units that contract public and private providers for covered populations
Course Outline:
Day 1: Provider Network Landscape, Payer Models and Network Baseline
- Payer Network Models Covering Open, Preferred and Exclusive Panels
- In-Network and Out-of-Network Steering Rules for Members
- Network Cost and Access Driver Map by Service Line
- Provider Market Concentration and Negotiating Leverage Assessment
- Current Network Baseline Map With Gaps and Overlaps
Day 2: Network Adequacy Standards, Provider Selection and Tiering Models
- Time-Distance and Travel-Time Access Standards by Specialty
- Provider-to-Member Ratio and Appointment Wait Access Metrics
- Ghost Provider Detection Through Directory Validation Calls
- Provider Selection Criteria Using Credentialing and Licensing Inputs
- Quality and Cost Tiering Model for Hospitals and Clinics
Day 3: Provider Contracting, Price Lists and Tariff Negotiation
- Provider Agreement Structure From Scope Schedule to Exit Clauses
- Price List Benchmarking Against Peer Tariffs and Cost Data
- Discount-Off-Charges, Fee Schedule and Package Rate Comparison
- BATNA and Concession Planning for Tariff Negotiation Rounds
- Negotiation Role-Play With a Hospital Group on Annual Tariffs
Day 4: DRG and Per-Diem Terms, Provider Scorecards and Contract Disputes
- DRG Base Rate, Relative Weight and Outlier Threshold Clauses
- Per-Diem, Stop-Loss and Carve-Out Terms for Inpatient Stays
- Provider Scorecard on Access, Quality, Cost and Service Indicators
- Contract Audit Rights, Tariff Variance Review and Recovery Steps
- Dispute Escalation, Corrective Action Plans and Termination Notice Handling
Day 5: Case Study on a Payer Provider Network Strategy and Contracting Plan
- Case Payer Network Adequacy Gap Analysis and Recruitment Targets
- Case Hospital Tiering and Member Steering Design Proposal
- Case Tariff Renewal Mandate With Target Rates and Walk-Away Points
- Case Provider Scorecard and Contract Audit Plan Drafting
- Provider Network Strategy and Contracting Plan Completion and Peer Defence
Skills You Will Gain:
- Network Adequacy Measurement
- Provider Tiering Design
- Price List Benchmarking
- Tariff Negotiation Planning
- Case-Rate Contract Drafting
- Provider Scorecard Design
- Contract Audit Review
- Provider Dispute Resolution
Why Attend This Course:
- Hand a Provider Network Strategy and Contracting Plan for a case payer to the head of provider networks and the chief medical officer
- Decide which providers to recruit, retier, renegotiate or exit, and on what tariff terms
- Avoid access gaps, above-benchmark tariffs and open-ended inpatient spend caused by weak outlier and stop-loss terms
- Share the adequacy worksheet, negotiation mandate template and provider scorecard with contracting colleagues
Conclusion:
Back at work, the participant gives the head of provider networks and the chief medical officer a Provider Network Strategy and Contracting Plan that sets adequacy targets, provider tiers, tariff mandates, contract terms and scorecard measures. Network managers use it to choose which providers to recruit or exit, and the contracting unit uses it to open the next tariff round. After the first renewal cycle, the unit should compare access gaps, unit cost per admission, scorecard results and open disputes with the baseline and revise the plan.
Frequently Asked Questions (FAQ):
What should participants know before a health insurance provider network management course?
Participants should already work in provider recruitment, contracting, provider relations or network analytics for a payer. Bringing an anonymised network list, a current price list or a provider agreement lets them apply each case study to their own network.
How does health insurance provider network management differ from a medical insurance operations course?
It concentrates on building the provider network and negotiating its contracts and tariffs. A medical insurance operations course covers benefit design, pre-authorisation and claims adjudication, and treats provider contracting only briefly.
Why does network adequacy matter in health insurance provider network management?
Adequacy shows whether members can reach the right provider within reasonable travel and waiting time. Without it, a payer may sign low tariffs with too few providers, leaving members facing access gaps, out-of-network bills and complaints.
What do participants take back from a health insurance provider network management course?
Participants take back a Provider Network Strategy and Contracting Plan for a case payer, with an adequacy gap analysis, a tiering model, a tariff negotiation mandate, a contract term checklist and a provider scorecard ready to adapt.