Challenges abound in the health care system. Lack of accurate data and outdated information creates a gauntlet for insurers when building health care networks.

From analysis, strategy, and expansion to provider credentialing and minimizing corrective burdens, TOG Network Solutions endeavors to accelerate significant changes in health care delivery across the nation.

TOG offers practical knowledge and a tailored suite of services for health care insurers seeking to build value and improve efficiencies while lowering costs.

Services

Network Analysis & Strategy
Provider Recruiting & Contracting
Provider Data Management
Compliance & Corrective Action Plan Mitigation (CAP)
Network Analysis & Strategy

From scrutinizing network information to finding the correct resources, TOG Network Solutions uncovers opportunities and designs tactics to grow and optimize health care for insurers.

Provider Recruiting & Contracting

TOG’s expert team of recruiters has the deep knowledge and expansive connections to enroll physicians, hospitals, and ancillary providers into networks.

  • Commercial: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Exclusive Provider Organizations (EPO), Point-of-service (POS), High Deductible Health Plans (HDHP).
  • Exchange: Small Business Health Options (SHOP) and individual (HMO, PPO, EPO, POS).
  • Medicare Advantage: Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-for-Service (PFFS), and Special Needs Plans (SNPs).
  • Medicaid: Temporary Assistance for Needy Families (TANF); Women, Infants, and Children (WIC); State Children’s Health Insurance Program (S/CHIP); Supplemental Nutrition Assistance Program (SNAP); National School Lunch Program (NSLP).
  • Tribal: Indian Health Service (IHS).
  • Military: TRICARE, Veterans Health Administration (VHA).
  • Behavioral: Adult, Child, and Adolescent, Geriatric, Addiction, including both facilities and professionals (Psychologists, Social Workers, Licensed Professional Counselors, Psychiatric/Mental Health Nurse or Nurse Practitioners).
Provider Data Management

In an industry that must often navigate the pitfalls of maintaining frequently accurate and consistent data, TOG understands the importance of keeping crucial provider information up-to-date through its proprietary data management platform.

Compliance & Corrective Action Plan Mitigation (CAP)

TOG knows that CAPs are costly and time consuming. For over a decade, TOG has worked with companies to develop clear guidelines to both resolve and prevent state and federal compliance actions.

Results & Testimonials

+“TOG’s robust platform is a market leader for network management. The platform’s 24/7 access coupled with their strong contracting experience and processes enabled our health plan’s key decision makers to quickly make strategic decisions (and ultimately have a very successful network expansion)”
+“Compliance in network management is not an easy feat for any managed care companies, and TOG exceeded our expectations at every front. Their attention to detail, commitment to quality, and robust reporting is second to none in the industry”
+“Having worked with other provider network vendors in the past, I was skeptical that TOG would be able to provide my organization with what we needed to resolve our adequacy concerns. Any and all concerns were swiftly alleviated within the first round of communication. The TOG Network Team worked collaboratively, communicated clearly and effectively, provided quality provider network leads, and most importantly produced tangible results that bolstered our provider network strength. TOG clearly has the necessary industry knowledge, relationships, and technical skills to help build a provider network needs to offer adequate care for our members.”
+“Thanks for delivering on TN network build in a short time frame and delivering the best network in the state. Being under budget and on schedule is something few companies do well and TOG delivered! Many thanks to you and your team for an outstanding job!”

TOG Glossary

Area Agency on Aging (AAA)
A state-designated public or private nonprofit agency that addresses the concerns and needs of all older persons at the local and regional levels. All Area Agencies on Aging receive federal funding under the Older Americans Act and most receive supplemental funding from local and state revenues.
Accountable Care Organization (ACO)

A health care model focusing on the clinical integration of a network of providers with incentives for providing care that emphasizes quality and reduces overall utilization. This type of coordinated care requires a number of core competencies that must be addressed in order for the ACO to be successful, including:

 

  • Developing Physician Leadership
  • Changing Participating Physician Behavior
  • Development of Processes for Integrating the Continuum of Care
  • Implementing Information Technology Systems to Measure and Report on Quality and Cost
  • Developing a Compensation Model to Give Physicians Incentive to Participate
  • Marketing the Concept to Payers and Patients to Build Volume and Drive Support
Behavioral health
Care that observes a person’s emotional, psychological, and social well-being, which includes treatment for mental health and substance-use disorders.
Centers for Medicare and Medicaid Services (CMS)
The government agency that administers programs for protecting the health of all Americans, including Medicare, the Marketplace, Medicaid, and the Children’s Health Insurance Program (CHIP).
Clinical Pathways (CP)
Structured, multidisciplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management, clinical audit and also financial management. CPs offer detailed guidance for each stage in the management of a patient (treatments, interventions etc.) with a specific condition over a given time period and include progress and outcomes details.

CPs may also be referred to as Integrated Care Pathways, Multidisciplinary pathways of care, Pathways of Care, Care Maps, and Collaborative Care Pathways.

Commercial plans
Health insurance provided and administered by non-governmental entities that can cover medical expenses and disability income for people who pay coverage for this insurance. These plans are regulated and overseen by each state. Two of the most popular types of commercial health insurance plans are the preferred provider organization (PPO) and health maintenance organization (HMO).
Comprehensive Error Rate Tests (CERTs)
A program CMS established to calculate a national paid claims error rate for the entire Medicare Fee-For-Service program.
Corrective action plan
A step-by-step plan developed and implemented to achieve targeted outcomes to resolve identified errors and their causes. One example involves updating out-of-date provider contact lists so information is correct on a website for those seeking medical care within a network.
Current Procedural Terminology (CPT)
A code set the American Medical Association maintains through the CPT Editorial Panel. This code set accurately describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.
Diagnosis Related Groups (DRGs)
A system used to classify hospital cases into one of approximately 500 groups, also referred to as DRGs, that are expected to have similar hospital resource use. Developed for Medicare as part of the prospective payment system, DRGs are assigned by a “grouper” program based on ICD diagnoses, procedures, age, sex, discharge status, and the presence of complications or comorbidities. Used in the US since 1983, DRGs determine how much Medicare pays the hospital, since patients within each category are clinically similar and are expected to use the same level of hospital resources.
Intellectually & Developmentally Disabled (DIDD)
State agencies responsible for administering support and services to residents with developmental and intellectual disabilities.
Department of Health (DOH)
A division of a local or larger government responsible for the oversight and care of matters regarding public health.
Department of Insurance (DOI)
The agency established to oversee and regulate all types of insurance sold within a state’s borders.
Electronic Health Record (EHR)

A systematic collection of electronic health information about individual patients or populations. It is a record in digital format capable of being shared across different health care settings, by being embedded in network-connected enterprise-wide information systems. These records can include a whole range of data in comprehensive or summary form, such as demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, and billing information.

Its purpose provides a complete record of patient encounters that allows the automation and streamlining of the workflow in health care settings and increases safety through evidence-based decision support, quality management, and outcomes reporting.

Electronic Medical Record (EMR)
Computerized medical record created in an organization that delivers care. EMRs are usually part of a local stand-alone health information system that allows storage, retrieval, and modification of records.
Episodes of Care (EOC)
All the clinically related services for a patient for a distinct diagnostic condition from the onset of symptoms until treatment is complete.
Evidence Practice Medicine (EPM)
An approach to practice and teaching established on the knowledge of the evidence upon which the practice is founded and the strength of that evidence. It involves integrating best current evidence with clinical expertise, pathophysiological knowledge, and patient preferences into the decision-making process for the care of individual patients.
Exclusive Provider Organization (EPO)
A type of health insurance plan in which services get covered only if the plan’s members go to doctors, specialists, or hospitals in a plan’s network. This excludes medical emergencies.
Federally Qualified Health Center (FQHC)
Safety net providers that offer services typically given in an outpatient clinic. FQHC’s can include the following: community health centers, migrant health centers, public housing primary care centers, and outpatient health facilities or programs operated by a tribal organization.
Health exchange
A service in every state also known as the health insurance Marketplace that helps people and small businesses buy affordable health insurance.
Health Information Exchange (HIE)
The electronic mobilization of healthcare information across organizations within a region, community, or hospital system. HIE has the ability to electronically move clinical information among different health care information systems and maintain the meaning of the information exchanged. HIE strives to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, effective, equitable, patient-centered care.
Health Insurance Portability and Accountability Act (HIPAA)

The rule that gives federal protections for personal health information held by covered entities and provides patients with a variety of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes.

HIPAA specifies a series of administrative, physical, and technical safeguards for covered entities to use to assure the confidentiality, integrity, and availability of electronically protected health information.

Health Maintenance Organization (HMO)
A network of health care providers and hospitals that have agreed to set terms of payment with an insurance provider with the goal of controlling costs for patients.
Health Savings Account (HSA)
A type of savings account that lets people put aside funds on a pre-tax basis to pay for qualified medical expenses. By using non-taxable dollars in an HSA to pay for deductibles, copayments, coinsurance, and some other expenses, people may be able to lower their overall health care costs. Generally, HSA funds may not be used to pay premiums.

While people can use the funds in an HSA at any time to pay for qualified medical expenses, they may contribute to an HSA only if they have a High Deductible Health Plan (HDHP) — a health plan (including a Marketplace plan) that only covers preventive services before the deductible.

Healthcare Common Procedure Coding System (HCPCS Codes)

A system of coding that Medicare uses which Centers for Medicare & Medicaid Services monitors. These codes are based on the Current Procedural Technology codes the American Medical Association developed.

Healthcare Effectiveness Data and Information Set (HEDIS)

A tool that more than 90 percent of America’s health plans use to measure performance on important dimensions of care and service. HEDIS consists of 71 measures across eight domains of care. Because so many plans collect HEDIS data and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an “apples-to-apples” basis.

Health plans also use HEDIS results themselves to see where they need to focus their improvement efforts.

High Deductible Health Plans (HDHP)
A type of health insurance plan with a higher deductible and lower premium. This form of insurance is typically acquired to cover catastrophic health events rather than non-urgent care.
Home Healthcare Agency (HHA)
Care which includes skilled nursing care and other skilled care services like physical and occupational therapy, speech-language therapy, and medical social services. The home health team provides, and helps coordinate, the care and/or therapy that a person’s doctor orders.
In Network Provider (IN)
A list of doctors and other health care providers that are currently contracted with a person?s insurance company for reimbursement at a negotiated rate.
Managed care
A type of health insurance. Insurers have contracts with health care providers and medical facilities to provide care for members at reduced costs. These providers make up the plan’s network.
Marketplace plan
A type of health coverage that an individual can purchase through a health exchange or health insurer.
Medicare
The federal health insurance plan for people who are 65 years or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). The different parts of Medicare help cover specific services such as hospital care (Part A); certain physician services, outpatient care, medical supplies, and preventative services (Part B); and prescription drug coverage (Part D).
Medicare Advantage
A type of Medicare health plan offered by a private company contracting with Medicare to provide all Part A (hospital care) and Part B (doctor office visits, preventative screenings and tests) benefits. Most Medicare Advantage Plans also offer prescription drug coverage. If a person is enrolled in a Medicare Advantage Plan, most Medicare services are covered through that plan. Their Medicare services aren’t paid for by original Medicare.
Medicare Reimbursement Scale
A listing of fees that Medicare uses to pay doctors or other providers/suppliers. This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service basis. CMS develops fee schedules for physicians, ambulance services, clinical laboratory services and durable medical equipment, prosthetics, orthotics, and supplies.
Medicaid
The federal and state-funded insurance plan that offers health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Medicaid is administered by states, according to federal requirements.
Medigap
A type of Medicare Supplement Insurance that helps fill “gaps” in original Medicare which private companies sell. Original Medicare pays for much, but not all, of the cost for covered health care services and supplies.
Military health care
The enterprise within the U.S. Department of Defense that provides health care to active duty, reservist, and retired U.S. military personnel and their dependents. Military health care sometimes gets administered through a third-party insurer.
Managed Long Term Services and Support (MLTSS)
The delivery of long-term services and supports through capitated Medicaid managed care programs. An increasing number of states are using MLTSS as a strategy for expanding home- and community-based services, promoting community inclusion, increasing efficiency, and ensuring quality.
Nation Wide Health Information Network (NHIN)

The entity that provides a secure, nationwide, interoperable health information infrastructure connecting providers, consumers, and others involved in health and health care. It will allow health information to follow the consumer, be available for clinical decision making, and support appropriate use of healthcare information beyond direct patient care so as to improve health.

National Committee for Quality Assurance (NCQA)
A private, not-for-profit, 501(c) (3) organization dedicated to improving health care quality whose mission is to bring health care quality to the forefront of the national agenda.
National School Lunch Program (NSLP)
A federally assisted meal program operating in public and nonprofit private schools and residential child care institutions. NSLP gives children nutritionally balanced, low-cost or free lunches each school day. It was established under the National School Lunch Act and signed by President Harry S. Truman in 1946.
Network analysis
A means to understand and manage health care. An analysis can reveal hidden structures distinct from formal structures, such as physician groups. The analysis can identify patients who might be best managed together and physicians who might best lead in health care interventions.
Network development
The act of building a healthcare network through various criteria, including, but not limited to, establishing clinical standards, selecting physicians, standardizing claims processes, monitoring costs, and working with insurance companies.
Network providers
A list of the doctors and other health care providers and hospitals that an insurance plan has contracted with to provide medical care to its members. These providers are called “network providers” or “in-network providers.”
National Plan and Provider Enumeration System (NPPES)
The federal system that assigns NPIs, maintains and updates information about health care providers with NPIs, and disseminates the NPI Registry and NPPES Downloadable File.
National Provider Identifier Standard (NPI)

A unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use NPIs for administrative and financial transactions adopted under HIPAA.

Out of Network Provider (OON)
A list of doctors and other health care providers that has not contracted with a person’s insurance company for reimbursement at a negotiated rate.
Payer
The business/insurer that handles financial and operational aspects of providing health care to American citizens.
Point-of-service (POS)
A type of health plan in which a person pays less if they use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans also require a referral from a primary care doctor in order to see a specialist.
Paid Provider Organization (PPO)
A type of health insurance plan that gives a person more flexibility with their medical care. They don’t need a primary care physician and can visit any health care provider without a referral, either inside or outside of a network. Those who stay inside their network have smaller provider visit copays and receive full coverage; those who decide to go outside their network will have higher out-of-pocket costs with no guarantee of coverage for all services.
Pay for Performance (P4P)
A payment model in health insurance where providers get rewarded for meeting pre-established targets for delivery of health care services. Also referred to “value-based purchasing,” P4P rewards physicians, hospitals, medical groups, and other healthcare providers for achieving certain performance measures for quality and efficiency.
Provider Led Entity (PLE)
A national professional medical specialty society or other organization consisting primarily of providers or practitioners who, either within the organization or outside the organization, principally offer direct patient care.
Private-Fee-for-Service (PFFS)
A type of Medicare Advantage Plan (Part C) that private insurance companies offer. PFFS plans aren’t the same as original Medicare or Medigap. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much a person must pay when they receive care.
Provider credentialing
The process of organizing and verifying doctors’ professional records. Hospitals and other organizations must legally verify providers’ identities, education, work experience, malpractice history, professional sanctions, and license verifications to protect patients from unqualified providers.
Qualified Medical Expenses
Typically the same types of products and services that can be deducted as medical expenses on an annual income tax return. Some Qualified Medical Expenses, such as doctors’ visits, lab tests, and hospital stays, are also Medicare-covered services.
Quality Improvement Organizations (QIO)
A program by law whose mission aims to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries.
Small Business Health Options (SHOP)
A program that assists businesses in providing health coverage to their employees.
Special Needs Plan (SNP)
A Medicare Advantage coordinated care plan which offers targeted care and limited enrollment to special needs individuals. A special needs individual can include a person in an institution, who is eligible for an Institutional Needs Plan (iSNP); an individual who is “dual eligible” and qualifies for a Special Needs Plan (DSNP) and enrolled in Medicaid and Medicare; and a person with a severe or disabling chronic condition as specified by CMS.
State Children’s Health Insurance Program (S/CHIP)
A program funded jointly by states and the federal government. S/CHIP offers health coverage to eligible children through Medicaid and separate S/CHIP programs. S/CHIP is administered by states, according to federal requirements.
Supplemental Nutrition Assistance Program (SNAP)
The national nutrition assistance program administered by the U.S. Department of Agriculture. SNAP provides nutrition benefits that supplement the food budget of needy families so they can purchase healthy food.
Temporary Assistance for Need Families (TANF)
A program that gives grant funds to states and territories to provide families with financial assistance and related support services.
Tribal health care
Health care services covered under a health insurance plan directed to Native Americans who are members of a federally recognized tribe.
Value-based program
A program that allows health insurers to reimburse providers based on the quality, rather than the quantity, of care they give patients. Under value-based care agreements, providers get rewarded for helping patients improve their health, reduce the effects and incidence of chronic disease, and live healthier lives in an evidence-based manner.
Women, Infants, and Children (WIC)
The Special Supplemental nutrition program for women, infants, and young children that provides federal grants to states for supplemental food, health care referrals, and nutrition education. This program targets low-income pregnant, breastfeeding, and non-breastfeeding postpartum women and infants and children up to age five who are found to be at nutritional risk.