Insights
Field notes from network builds. Not white papers.
Playbook excerpts, regulatory reads, and essays on day-to-day network operations. Written from inside the work.
More from the playbook
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- Regulatory
The Medicaid Access Rule: Wait-Time Standards Are Coming
The Medicaid Access Rule sets appointment wait-time standards, secret-shopper surveys, and a phased timeline that health plans and IPAs must prepare for now.
14 min - Regulatory
Behavioral Health Network Adequacy: The New CMS Standards
Behavioral health network adequacy is now a first-class CMS standard. Here are the 2024-2026 rule changes and how to build a compliant network.
14 min - Strategy
After ACO REACH: What the 2026 Sunset Means for Your Network
ACO REACH ends after performance year 2026. An accurate look at the LEAD Model, MSSP, ACO PC Flex, and MA contracting, and how your network changes.
14 min - Strategy
Building Networks for MA Supplemental Benefits
A supplemental benefit network strategy for Medicare Advantage plans facing CMS scrutiny, bid-to-benefit pressure, and benefits members struggle to use.
14 min - Regulatory
The Health Equity Index and Your 2027 Star Ratings
The Health Equity Index reward will not take effect for 2027 Star Ratings, but equity-focused network design still drives quality for dual and LIS enrollees.
14 min - Strategy
Vertical Integration: A Playbook for Independent IPAs
How payer-provider vertical integration is reshaping provider networks, and a practical playbook for independent IPAs to preserve leverage and contract terms.
14 min - Regulatory
Network Design for C-SNPs and I-SNPs
How to design provider networks for C-SNPs and I-SNPs: specialist mix, institutional facilities, model of care, and CMS adequacy for special needs plans.
14 min - Credentialing
AI in Provider Data and Credentialing: What Is Real Now
A grounded 2025-2026 view of AI in provider data and credentialing: what automation genuinely helps, what is hype, and where NCQA rules keep humans essential.
14 min - Strategy
Virtual-First Provider Networks: A Strategy for Plans
A virtual-first network strategy for MA and Medicaid: how telehealth counts toward adequacy, hybrid design, cross-state licensure, and in-person limits.
14 min - Regulatory
When you can't meet adequacy: CMS exceptions, explained
A CMS network adequacy exception is a last resort, not a strategy. Learn when CMS grants one, how to document a request, and why to build first.
8 min - Strategy
Build vs. outsource: staffing a provider network function
Should you hire an internal contracting and credentialing team or use a consultancy? A practical look at true cost, timeline, deadline risk, and hybrid models.
8 min - Regulatory
Ghost networks: why provider directories lie — and how to fix yours
Ghost networks break access and trigger enforcement. Learn why provider directories go stale, what CMS and the No Surprises Act require, and how to fix yours.
12 min - Regulatory
How telehealth counts toward network adequacy
CMS gives Medicare Advantage plans a 10-point telehealth credit for certain specialties. See how it works, which specialties qualify, and how to use it honestly.
11 min - Strategy
Star Ratings start in the network.
How your provider network drives Medicare Advantage Star Ratings, and why most plans don't connect the two until they're chasing a 3.5.
8 min - Contracting
Single Case Agreements: the release valve for network gaps
A single case agreement covers one member when your network has a gap. How SCAs and letters of agreement work, how rates get set, and the compliance risks.
8 min - Strategy
Value-based contracts require a different network.
Moving from fee-for-service to value-based arrangements changes more than how you pay providers. It changes who you contract with and what they need to be able to do.
8 min - Regulatory
ACA Marketplace network adequacy: the QHP standards, explained
Entering the ACA Marketplace? Learn the QHP network adequacy standards — time-and-distance, wait times, ECP thresholds — and how they differ from Medicare Advantage.
12 min - Regulatory
Essential Community Providers: the Marketplace requirement plans underestimate
The ECP standard trips up Marketplace filings every year. What Essential Community Providers are, the 35% CMS threshold, write-ins, and how to build early.
8 min - Regulatory
The CMS application calendar every new MA entrant needs to know.
The Medicare Advantage application cycle runs on a fixed annual calendar, and network adequacy documentation is always the last thing ready.
7 min - Contracting
Benchmarking fee schedules to Medicare — and negotiating from there
Why provider fee schedules are set as a percent of Medicare, how to build a defensible benchmark by specialty and geography, and how to negotiate from there.
9 min - Regulatory
D-SNP integration: SMACs, EAEs, and what changed
CMS is pushing D-SNPs toward tighter Medicaid integration. Understand SMACs, Exclusively Aligned Enrollment, applicable integrated plans, and network impact.
9 min - Regulatory
What CMS actually looks for in a network adequacy filing.
The mechanics of a CMS network adequacy submission: what goes in, what reviewers flag, and what triggers an RFI.
8 min - Contracting
The anatomy of a participating provider agreement
A plain-English walkthrough of the key clauses in a participating provider agreement — and the ones that quietly cause problems long after the contract is signed.
9 min - Strategy
HEDIS starts in the network: designing for quality measures
HEDIS scores are decided by which providers you contract and the data they return. Learn which measures are network-sensitive and how to build for quality.
8 min - Operations
Running a credentialing committee that doesn't slow the build.
Most credentialing committees are structured for compliance, not velocity. Here's how to design one that meets NCQA standards and keeps pace with a network build.
6 min - Operations
Continuity and transition of care when a provider exits
When a provider leaves the network or a member is mid-treatment, continuity-of-care rules protect the patient. Learn the timelines and how to operationalize them.
8 min - Operations
From signed to payable: closing the provider onboarding gap
A signed contract is not a working provider. Learn the steps between signature and a credentialed, loaded, directory-listed, payable provider, and how to track them.
8 min - Operations
Delegated credentialing: what the contract actually says.
Delegation agreements with hospitals and health systems can speed up credentialing or create compliance problems. The difference is in exactly what you're delegating.
7 min - Playbook
The diagnostic, not the deck.
Why a two-week diagnostic that puts a name on every fix outperforms a six-week strategy engagement, every time.
6 min - Playbook
The first five providers to contract in a new county.
Sequencing matters in a county-level network build. Not all providers are equally important at the start. Here's the order that moves the adequacy clock fastest.
6 min - Strategy
When your IPA isn't ready for the risk it's taking on.
IPAs that accept financial risk before their infrastructure can support it are the most common failure mode we see. Here's what readiness looks like in practice.
7 min - Regulatory
Adequacy is a living target.
CMS time-and-distance standards, state DOI rules, and federal exchange requirements keep shifting. Here's how to build a network that anticipates the next review instead of scrambling after it.
9 min - Operations
Credentialing is the critical path. Treat it that way.
Credentialing should set your go-live date, not the other way around. Why that matters, and how to staff for it.
7 min - Playbook
Medicaid managed care networks are not Medicare Advantage networks.
Plans entering Medicaid managed care from an MA background face a different adequacy framework, a different provider population, and a different compliance environment.
8 min - Operations
The weekly cadence.
What a network management leadership review looks like in the room, agenda included.
5 min - Contracting
The provider contract amendment cycle most plans let slip.
Fee schedule updates, quality addenda, and value-based modifications happen annually. Most plans have no formal process for managing them, and providers notice.
6 min - Regulatory
Directory accuracy isn’t optional anymore.
The No Surprises Act, state penalties, and the operational discipline required to keep your directory honest.
8 min - Playbook
Why builds stall in week six.
The pattern repeats on nearly every build. This is the point where the plan meets reality, and why it always hits the same way.
7 min - Contracting
The fee schedule conversation nobody wants to have.
Fee negotiations are where provider relationships get made or broken. Here’s how to have the conversation in a way you can live with for the next decade.
7 min - Playbook
What you inherit when you take over a stalled build.
Inheriting a build in progress is one of the harder engagements there is. Here’s what to do in the first five days.
8 min - Operations
Rural providers require a different playbook.
The standard outreach model was designed for suburban commercial networks. Rural providers have different economics, different leverage, and different reasons to say yes.
6 min - Operations
The 60-day credentialing clock.
NCQA allows a 60-day provisional credentialing window. Your go-live date lives inside it, and most plans don’t plan for it until it’s a problem.
7 min - Contracting
When a provider says no.
The three most common reasons providers decline to join aren’t the ones you expect. Two of them are recoverable.
6 min - Regulatory
How CMS actually measures time and distance.
Most people have a general sense of time-and-distance standards. The specifics are where plans get surprised: who runs the calculation, which county type you're in, and how the percentage test works.
8 min - Regulatory
D-SNP is a different network problem.
D-SNP adequacy requirements differ from standard Medicare Advantage in ways that matter at the build phase. Here’s what changes and what doesn’t.
7 min - Regulatory
Behavioral health adequacy is its own build.
In network builds, behavioral health adequacy is usually the last thing standing. Here’s why it’s its own problem and how to treat it that way.
9 min - Regulatory
Provider attrition is the adequacy you’re not watching.
Network adequacy is not a one-time achievement. It’s a condition you maintain, and attrition is the force that works against you every week.
7 min - Operations
CAQH hygiene is network hygiene.
CAQH underpins most credentialing workflows. When the data is stale, the credentialing process stalls. The maintenance program is straightforward. Most organizations just don’t have one.
6 min - Contracting
Contracting with health systems is a different game.
Large health systems operate on different contracting timelines, with different internal decision-making structures. What works for independent physicians rarely works here.
8 min - Playbook
Building a first-year MA plan’s network.
First-year Medicare Advantage applications are the most time-constrained builds in this business. The CMS timeline leaves less room than most organizations expect.
9 min - Playbook
What ‘go-live’ actually means.
’Go-live’ means four different things to four different stakeholders. Confusing them has real operational and regulatory consequences.
6 min - Operations
The hand-back.
Every build we run is designed to end with your team running a working operation. What the package contains and how to set the new team up to hold it.
7 min - Operations
Provider data operations is nobody’s job.
Provider data lives in the gap between your credentialing system, contracting system, claims system, and directory. Nobody owns that gap by default.
8 min - Regulatory
Building a network for ACO REACH.
ACO REACH entities have network requirements that don’t map neatly onto Medicare Advantage frameworks. Here’s what’s different and where the build starts.
7 min - Strategy
Market entry sequencing: where to launch first.
The question isn’t whether to build in a given market. It’s which county to stand up first. That decision has outsized consequences for everything that follows.
8 min - Regulatory
The No Surprises Act changed what a network gap costs.
The No Surprises Act was framed as a billing reform. For commercial and Marketplace plans, its effect on the cost of thin networks and on contracting leverage is larger than most plans planned for.
7 min - Operations
The provider relations function most networks skip.
Provider outreach gets the contract. Provider relations keeps the provider. Most network organizations fund the first and skip the second.
6 min
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