High-Quality Provider Network

A high-quality provider network is a critical component of an Employee Assistance Program (EAP). The professionals with whom you contract to provide counseling services are the collective face of your EAP, and can determine the success or failure in the delivery of quality EAP services. Developing and maintaining a high-functioning provider network is a dynamic process that requires strategic planning and execution, as well as consistent monitoring and maintenance by an experience and specialized team.

Recruit and Select Highly Qualified Providers

Building a high-quality network requires the establishment of solid professional competencies. The following minimum standards for EAP providers are suggested:

  • five years of post Master’s degree direct clinical experience,
  • three years of experience providing EAP counseling,
  • independent license at the highest level of practice in state of residence,
  • license in good standing, with no sanctions,
  • malpractice insurance $1M per occurrence/$3M in the aggregate,
  • an assessment of provider’s knowledge of EAP practice, such as via interview and requirement the provider complete an “EAP 101” training program. The Certified Employee Assistance Professional credential should be considered as essential.
  • Special consideration should be given to providers who are members of EASNA and EAPA.

Primary Source Verification

Primary Source Verification means the appropriate state or professional regulatory body that originally conferred or issued the credentialing element to the practitioner validates credentialing information. For example, counseling licenses are verified by respective State Licensure Boards to confirm the license or certification is active, and also to reveal any past or current sanctions against the provider’s license. A photocopied license provided by the individual is not considered adequate to verify the credentialing document. The Office of Inspector General background checks ensure no history of disqualifying offenses exist, such as fraud, patient neglect, or even defaulting on student loans. The National Student Clearinghouse verifies graduate degrees.

 

Right-size Your Network

Quality provider networks are a balance between successfully meeting participant need, provider need, and an ability to sufficiently administer and maintain the network. Quality EAPs ensure at least a 95% match of providers within 25 miles of all participant locations.  Your network should be of sufficient size to ensure your providers receive a steady stream of referrals, and stay closely connected with the services and support your EAP offers.

 

Identify High Need Gap Areas

Run GeoAccess reports on a periodic basis to evaluate and identify areas of high need, as well as areas in which there are gaps in coverage. The GeoAccess report should analyze the availability of network providers to the contracted corporate client locations and the corporate clients’ employee population count.  High-need areas are identified by dividing the number of cases referred by the number of providers referred to in a given geographic area over a period of time. The higher the ratio, the more providers are needed in that area.

Identify trends in temporary or ad hoc provider requests to reveal areas of needed provider recruitment. For example, requests for foreign language-speaking providers may be more prevalent in a particular area, or, substance abuse professionals may be in high demand in another region.

 

Hire Highly-Educated, Experienced Provider Network Staff

A quality provider network requires a strategy and action plan to maintain evidence of credentials, operational support of providers, ongoing recruitment and network develop efforts, provider consultation and supervision protocols, and a continuous quality assurance plan. The staffing necessary to complete these functions can be impacted by the size and complexity of the network. Recommended staffing includes:

  • Provider network program director or manager – tasked with the responsibility to manage and oversee all provider network requirements, needs, challenges, and quality assurance processes.
  • Provider network coordinator–typically a licensed and experienced clinician tasked with the responsibility to provide clinical oversight and support the network manager in daily operational oversight of the provider network.
  • Provider network specialists–tasked with the responsibility to assist in provider recruitment, addressing client-specific service needs, assisting with quality assurance processes.
  • Credentialing specialists–tasked with the responsibility to ensure primary source verification processes are in place and conducted on a scheduled basis.  EAPs may make use of qualified credentialing vendors to assist in this process.
  • Operations assistance–tasked with functional support for provider network direct service staff.

 

Utilize Fair-Market Reimbursement Rates

Typically, EAP services are prediagnostic and include the opportunity for clients to receive a telephonic assessment prior to authorized in-person services, which can translate to a more effective and efficient clinical assessment process for providers. Further, EAP service providers need not be muddled with the billing and reimbursement challenges that can exist with insurance-based care. As a result, EAP service delivery and reimbursement protocols are streamlined. Providers can serve more effectively and are reimbursed quicker. Your EAP needs to carefully evaluate the usual a customary behavioral health service rates experienced by providers in your overall provider network area. Consideration should be given to establishing commensurate rates for specialty services (i.e., DOT evaluations), trauma response services, and case management services.

Establish clear and well-supported policies for how you will reimburse your providers. Consideration should be given to such factors as these:

  • rates for prompt and accurate paperwork completion,
  • for late and inaccurate paperwork completion, and
  • paperless documentation.

 

Be Accessible and Responsive to Your Providers

Accessibility and responsiveness to the providers is crucial to maintaining a successful provider network. Your providers directly impact your customers, at a very personal level, and deserve excellent customer service, which fosters their own excellent customer service. Offer a live-answer provider helpline to answer providers’ calls. Strive to answer 100% of provider calls.  If voicemail messages are left, return those calls promptly, preferably same-day.

Develop a secure, user-friendly, online provider portal to streamline such services as:

  • provider application,
  • service authorizations and clinical assessment information,
  • case note documentation,
  • referral tracking,
  • claims-payments, and
  • access to support documents, including clinical paperwork, handouts, guides, etc.

Paperwork and administrative requirements should be streamlined. Simplifying paperwork will make your network more attractive to busy, highly qualified providers.

 

Regularly Monitor Your Network–Reduce Your Risk

Establish a quality assurance process for your provider network providers and protocols. Monitor and evaluate those providers who may have demonstrated patterns of challenge or service problems. Ensure your quality assurance process is integrated into the overall EAP organization’s quality assurance initiative.

Develop a plan and protocol for reviewing all provider service complaints, concerns, and sanctions. Assign remedial action plans depending upon the seriousness of any issues that arise with network providers. Use a severity-rating scale that provides guidance on the remedial action plans that may occur with providers, including clear decision-making protocols for when provider service contracts may be terminated. Your remedial action protocols must include right to appeal provisions, to ensure providers have sufficient mechanisms to question important steps in the investigation process. Develop protocols to ensure the monitoring of providers at a variety of levels, including:

  • primary source verification,
  • case/record review and consultation, and
  • auditing of clinical and billing paperwork.

Ensure you have matched all network monitoring processes to clearly documented service standards.

 

Communicate Regularly With Your Network

Develop a process to provide scheduled and as-needed updates to your providers.  Consideration can be given to sending your providers a quarterly newsletter in which clinical best practices are reviewed, and information about your EAP services and programs is shared. The use of e-newsletters and/or a secure web portal is recommended.

Consider establishing a provider advisory committee comprised of exemplary providers who represent your network community in different geographic regions. Meet quarterly and solicit feedback about what is working, what is not, and how to improve overall EAP service delivery and operations. Through their feedback and collaborative participation, those provider representatives advance the quality, effectiveness, and success of services to participants, and stay engaged and committed to serving you and your clients.

Click here for a copy of this High Quality Provider Network report.

Posted on Developing and Maintaining a High-Quality EAP Provider Network, EASNA News