Comprehensive PPO Network: Balancing Local Insight with National Coverage 

Sally Ferguson, Vice President Provider Network Innovation, and Catherine Cain, Director of ePPO Product Manager 

In the realm of workers' compensation and managed care, access to a reliable and expansive provider network is crucial. At their largest, national PPO networks could be comprised of upwards of a million providers, covering the gamut of niche specialists to general practitioners. However, sheer size doesn’t always equate to impact. Without the utilization of local PPO network developers and affiliate partnerships to fill in the gaps, the expansive reach of national PPO network can only go so far. 

Local PPO network developers play a pivotal role in network enhancement and customization by being the eyes and ears on the ground. Not only do they help maintain and manage access to large networks, but they provide deep local expertise. However, true comprehensive coverage doesn't just begin with a national PPO network and end with local network developers -- in the middle of it all is affiliate network partnerships. These partnerships are an essential piece of the coverage puzzle to ensure access to primary and specialty care is available for all injured workers. 

To effectively meet every employee’s care needs, optimize their recovery, and deliver better outcomes, PPO networks must reflect the balance of national coverage with local insight and lean on affiliate network partnerships to fill in the gaps.  

The Role of Local PPO Developers 

Local PPO network developers serve a few different purposes within workers’ compensation and managed care. Not only are these network developers’ jurisdictional experts, but they also serve as government-provider liaisons and local relationship holders – each of which contributes to a truly comprehensive network.  

Jurisdictional Experts and Provider Liaisons:  

Each state’s laws and provider reimbursements are unique. Because of this, it’s nearly impossible to have network-level national expertise on the ever-changing provider reimbursements and regulations landscape. As the eyes and ears on the ground, local network developers serve as jurisdictional experts, attuned to proposed laws and forthcoming changes. This knowledge enables them to proactively alert providers of new administrative rules or other nuances in reimbursements before bills are signed into law.  

Another part of what makes local network developers an essential piece of a comprehensive PPO network is their access to hyper-localized insights. Armed with community-specific data, network developers are able to manage local recruitment, negotiate contracts, and oversee credentialing processes. This approach not only strengthens provider relationships but also ensures networks are finely tuned to meet local healthcare demands and regulatory requirements. 

Relationship holders:  

The relationships between local network developers and their provider community are invaluable. Aside from the obvious benefits of direct lines of communication and support to the providers, these network developer-provider relationships also serve as a channel to eliminate inefficiencies throughout the claims management process. 

According to a CorVel PPO provider, “Timely authorization and the ability to direct documentation through the appropriate channels to promote case velocity ultimately set an injured worker up for success. Our local contacts can easily connect a provider to the appropriate team member assigned to the account. This streamlined approach enables improved communication while decreasing utilization and encourages a timely return to work.” 

To help bring this idea further to life, here’s an example: A member of CorVel’s bill review team flags a specific pattern on a provider’s billing where documentation does not support the charges submitted to their local network developer. Instead of experiencing delays in the claims process due to a billing discrepancy, a local network developer may help facilitate a face-to-face meeting with the provider to resolve this issue quickly and effectively. This connection would help eliminate unnecessary friction within the bill review process and reduce provider frustration by proactively identifying billing errors and addressing them on-site, while building upon an existing provider partnership. 

Network development encompasses not only the responsibility of maintaining relationships and contracting with providers within their respective jurisdictions but also extends to forming affiliate partnerships." 

Affiliate Partnerships, Filling in the Gaps 

Affiliate partnerships can come about in a couple of ways, but typically, these relationships form if a client has an existing relationship with a PPO network or has a specific need that can be met through the affiliate network. These partnerships are often used to fill in gaps in care, where the existing PPO network does not reach. 

When we refer to gaps in care, we mean any lapse in access to care for injured workers, ranging from a particular specialty that’s not necessarily workers’ compensation-focused to complex and rare cases, or even in an especially rural area where there needs to be more coverage and improved access to care. The broader network offers more options preventing delays in the injured worker obtaining needed care and minimizing wait times for an appointment.   Additionally, there is an increased probability that the injured workers’ primary health care physician is included in the network, resulting in continuity of care.  

Ultimately, these partnerships provide coverage and specialists for clients to offer their insureds or employees for treatment with the goal of timely return to work. 

Without the use of affiliate partnerships to fill in these gaps and augment core PPO networks, the most expansive, national network is just that – expansive, but not comprehensive. 

At the end of the day, national PPO networks, local network developers and affiliate partnerships are guided by the same principles: expanding access to high-quality care for injured workers and optimizing injured workers’ recovery and return-to-work.  

Striking the Balance 

An expansive PPO network – balanced with local network developers and affiliate partnerships -- introduces injured workers to a healthcare experience with vetted providers and high standard, outcome-focused services. 

There’s no denying the healthcare provider landscape is undergoing a period of change due to high volumes of vertical integrations and mergers and acquisitions. This wave of provider consolidation has ripple effects such as continued gaps in access to care, delays when choosing the right provider, and an overall negative impact on the injured worker’s recovery. To mitigate these potential downsides, comprehensive PPO networks look to combine expansive national coverage with localized expertise, offering clients a robust framework to manage healthcare costs effectively while ensuring high-quality care delivery. 

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