If your medical practice wants to join more ACA Marketplace, Medicare Advantage, or commercial insurance plans, it’s important to know how carriers decide to expand their networks. Insurers usually don’t add providers just because a practice asks.
Instead, they look at whether adding a provider will improve network performance, member access, quality, and long-term value. Here are some key factors carriers consider before expanding their provider networks.
Network Adequacy is Always First
The main reason carriers expand a network is to meet regulatory network adequacy requirements. Federal regulations require health plans to maintain enough providers, across enough specialties and geographic areas, so that members can access care without unreasonable delays.
For practices, location is important. If you serve a fast-growing area, a rural community, or offer a specialty that’s in short supply, your chances of getting a contract often go up.
Patient Access and Appointment Availability
Carriers want their members to get care quickly. Practices that can regularly offer new patient appointments within a reasonable time are much more appealing than those already at full capacity.
The National Committee for Quality Assurance (NCQA) considers appointment access, provider availability, and continuity of care important for managing provider networks. Many carriers now ask about average wait times, office hours, telehealth options, whether you accept new patients, and if you have more than one office.
Quality Performance Matters More Than Ever
Today, carrier networks focus more on value than on volume. High quality scores can make your practice much more appealing when networks are expanding.
Carriers often review:
- Preventive care performance
- Chronic disease management
- Readmission rates
- Patient outcomes
- Patient satisfaction
- HEDIS®-related quality measures
NCQA accreditation standards also stress the need for ongoing quality checks and monitoring. Practices that take part in quality reporting or value-based care programs often have an edge.
Accurate Credentialing and Compliance
The best practice can’t join a network without full credentialing, so carriers review a practice’s active licenses, board certifications, malpractice history, current hospital privileges (and whether those hospitals are in the carrier’s network), sanctions or exclusions, and CAQH information.
NCQA standards require regular credential checks, monitoring for sanctions, and fair credentialing processes. Keeping your credentialing up to date can help avoid delays in contracting.
Reliable Provider Data
A growing challenge for carriers is keeping provider directories accurate. CMS requires many payers to keep public directories with provider names, specialties, addresses, and network participation.
Practices that quickly update carriers about changes in address, phone number, office hours, new patient status, or provider roster help improve the member experience and reduce paperwork.
Geographic and Specialty Gaps
Carriers constantly analyze where members are experiencing access issues. They often ask questions like:
- Do we have enough primary care physicians?
- Is behavioral health access limited?
- Are specialists concentrated in one area?
- Are members traveling too far for care?
If your practice helps fill one of these gaps, you become much more valuable when networks expand. Federal rules require networks to have enough providers of different types so members can get care without long waits.
Ability to Support Value-Based Care
Many insurers are adding providers who can support coordinated, data-driven care. Practices that show care coordination, work on population health, manage chronic diseases, use electronic data, report on quality measures, and offer care management programs are a better fit for what carriers want.
These skills improve patient outcomes and control healthcare costs, the most attractive aspects your practice exhibits for a future carrier contract. Joining a new insurance network now takes more than just having room for new patients.
Carriers want providers who improve patient access, deliver measurable quality with accurate data, finish credentialing quickly, and provide coordinated care. Independent practices that understand these priorities and implement them at your organization are more appealing now and in the future as networks keep growing.
Practices that make these changes build more trust with both patients and insurers. They do more than manage; they set themselves up for long-term success.
Patient Care Health (PCH) partners with carriers and practices to create the right mindset and systems for real growth. The most successful groups are those whose networks deliver real results, not just good plans.
Contact us to get started and let PCH help you achieve your network goals.
Phone: (866) 985-2010, Monday-Friday 9 A.M. – 5 P.M. CT
Email: info@patientcarehealth.com
