CASE STUDY

Mission:

Build a comprehensive statewide Medicaid network to position Kaiser Permanente Georgia for success in an upcoming request for proposal (RFP), while also expanding Medicare and commercial network coverage.

Project Overview

This build was to cover all provider specialty and facility types in accordance with health service delivery (HSD) adequacy requirements for Medicare and state Medicaid. Kaiser Permanente Georgia was also looking to expand Medicare and commercial network contracts in additional counties.

Challenges Met:

  • Rural Network Gaps:

    Minimal provider presence in certain counties, with large health systems lacking commercial/Medicare contracts, and slow progress with IPAs.

  • Demanding Partners:

    Large health systems requesting high rates or specialized payment models.

  • Changing State Requirements:

    A delayed RFP and multiple revisions of state requirements throughout the project.

Approach

TOG demonstrated flexibility and strategic thinking in the face of these obstacles. The team repeatedly adjusted network build strategies while navigating complex negotiations and shifting regulatory requirements.

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Results:

  • Contracting Excellence:

    Secured 631 contracts, establishing a robust network foundation for Medicaid and Medicare services over a challenging 22-month period.

  • Strategic Adaptability:

    Managed 46 regulatory amendments and initiated 177 LOIs, showcasing agility in expanding network coverage despite fluctuating requirements.