2020 State HIT Connect

Ensuring that Medicaid recipients have access to providers and services is a critical issue for states that administer Medicaid through managed care programs. Inadequate provider networks threaten the quality of care and can impede efforts to improve population health outcomes. Additionally, inaccurate data makes it difficult for organizations to understand gaps in coverage. Manual processes to validate provider networks both in terms of data accuracy and network adequacy are insufficient given the high volume of Medicaid providers. In recent years Pennsylvania, assisted by Deloitte, has successfully automated provider network validation processes. Machine learning, applied to provider network oversight, has enabled Pennsylvania to focus reviews on high-need specialties and to understand the true and actual networks of providers who are available to serve recipients.