APM CASE STUDY 2024

Problem statement
You are a PM at HiLabs and tasked to build a network management tool that leverages
publicly accessible price transparency data and advanced web scraping technologies to
compare and recruit providers from different health plans. The platform should have
actionable performance analytics (provider ratings, quality, cost, health outcomes) and
competitive analysis to make the insurer identify and recruit high value providers and build
high performing narrow networks.

Prakarsh dev (IIT Kharagpur)

prakarsh@kgpian.iitkgp.ac.in
21MI10038
8707664841
 Problem User Solution Technology Impact Wireframe Pitfalls

Breaking down the problem? Why solution is needed? Assumptions

For which industry are we solving the problem? How much does poor quality provider data cost organizations annually?
Healthcare Insurance. Poor quality provider data costs organizations over $2 billion annually.

What challenges do healthcare insurers face?

Ensuring network adequacy and data accuracy, How can optimizing provider networks affect overall network costs?
maintaining compliance with CMS standards, and Reduces costs by over 15%.
improving member access to quality providers.

Why is accurate provider information critical?

Accurate provider data ensures members can access
care smoothly, reduces compliance risks, and
supports network adequacy.

Why is provider recruitment challenging?

Finding qualified providers who meet adequacy standards,
cost-effectiveness, and geographic needs can be time-intensive.

What metrics define a high-value provider?

High-value providers often have strong quality ratings,
low costs, high accessibility, and positive health outcomes.

Why is provider comparison essential for network optimization?

Comparing providers enables insurers to identify top
performers and refine the network for quality and cost efficiency.

What challenges arise in tracking provider availability?

Provider availability changes frequently, making it difficult to
maintain up-to-date records and meet member expectations.

What additional factors should insurers consider?

HIPAA and data privacy compliance.
Adapting to CMS and state guidelines.
Scalable, integrated solution with legacy systems.
Source: U.S. Health Insurance Industry Analysis Report

HiLabs
 Problem User Solution Technology Impact Wireframe Pitfalls

| Target User | User Persona

Insurance Executives Hellen Roberts
Role: Oversee overall network operations, quality, and cost-effectiveness. Role: Network Strategy Manager
Company: MediConnect Health Insurance
Stakeholders:
|Responsibilities
Insurance Company
Hellen is responsible for optimizing MediConnect’s provider network to improve cost-efficiency,
Ensure their health plans meet regulatory requirements. quality of care, and competitive positioning.
Her duties include comparing provider performance metrics, ensuring network adequacy, and
recruiting high-value providers who meet quality and cost standards.
Federal / state Regulators She also performs competitor analysis to identify opportunities for building high-performing narrow
CMS (Centers for Medicare & Medicaid Services) networks.
State Departments of Insurance
Ensure health plans comply with network adequacy standards
| Goal
Build a provider network that is compliant, high-quality, with strong ratings, cost-efficient.
Leverage data-driven insights to streamline recruitment, lowering administrative costs and time demands.
Providers Maintain a network that fulfills CMS guidelines, adapting to state-specific compliance standards fully.
Healthcare practitioners who are part of the network.
| Pain points
Compliance officer Inefficient Recruitment: Recruiting providers with the right balance of quality and cost-effectiveness
requires significant time and resources
Conduct compliance checks, including surprise visits, to
ensure providers meet federal and CMS guidelines. Lack of Competitive Insight: Limited tools for comparing MediConnect’s network against competitors
make it difficult to identify valuable providers in the market.
Provider Attrition: Frequent provider turnover and status changes complicate network stability,
creating unexpected gaps that disrupt member access.
Members Manual Data Validation: Current manual processes are time-consuming, error-prone, and prevent quick
Beneficiaries of the health plans updates, affecting member satisfaction.
Poor Member Experience: Members struggle to find reliable, in-network providers easily.

HiLabs
 Problem User Solution Technology Impact Wireframe Pitfalls

| Process Overview | Reliability Check

Compliance Patient Formula: Each metric is assigned a weight based on its importance to overall reliability,
Provider Data
Checks Feedback
and the reliability score is calculated as a weighted average of all metrics.
Reliability
Check Reliability Score (RS) = (Satisfaction Level × Wn) + (Response Time × Wn) + (Service
Network Provider Performance
optimization Recruitment score Quality × Wn) + (Location Accessibility × Wn) + (Compliance Score × Wn)

| Key offerings Weights (W1 - W10): Adjusted weights based on level of scores
W1: 1 (Best), W3: 0.8 (Good), W5: 0.6 (Average), W8: 0.3
High Reliability: RS > 85
Moderate Reliability: 70 ≤ RS ≤ 85
Two-Step Verification: Ensures provider compliance with CMS and federal (Below average), W10: 0.1 (Worst) Low Reliability: RS < 70
guidelines, validated by member feedback.
Compliance Visits: On-site evaluations by skilled officers to verify provider | Reliability Scores
conditions and service quality.
Provider Performance Scoring: Rates providers on satisfaction, response time, Reliability Score Satisfaction Response Service Location
Compliance Score
benefits delivered, and accessibility. Level Range Level Time Quality Accessibility
Real-Time Feedback Loop: Collects member feedback to address issues and
continuously improve provider services with reliability checks. Meets or
Within 12 90+ within Fully compliant with
Competitive Health Plan Analysis: Compare health plans, giving competitive High 85 - 100 (Very exceeds CMS
RS > 85 hours adequate federal standards
insights and aiding in strategic recruitment of top providers. Reliability Satisfied)
90 - 100
standards
distance (100)
( 100 )
Ghost Network Detection: Identifies unavailable providers, allowing insurers to
address gaps, reduce ghost networks, and enhance overall network reliability.
Meets most
70 - 84 Within 24 75 - 89 within Mostly compliant, minor
Key Benefits of Patient Feedback Moderate
70 ≤ RS ≤ 85 (Moderately hours
CMS
adequate issues
Reliability standards
Satisfied) 50 - 90 distance ( 75 )
Improves Quality of Care: Identifies strengths and improvement areas. ( 75 - 100 )
Ensures Accountability: Holds providers to high care standards.
Measures Patient Satisfaction: Gathers insights on overall experience. Fails to meet
Below 75
Supports Compliance: Aids in meeting regulatory requirements. Low Below 70
Over 24 CMS
within
Non-compliant or
RS < 70 hours standards in significant issues
Promotes Continuous Improvement: Tracks and enhances care quality. Reliability (Dissatisfied) adequate
0 - 50 areas (0)
Builds Trust: Shows patients their feedback is valued. (0)
distance
Reduces Readmissions: Helps improve follow-up care and outcomes. Feedback Form

HiLabs
 Problem User Solution Technology Impact Wireframe Pitfalls

| Step 1: Provider Comparison and Data Validation |

Technology Components:
| Process Flow
Price Transparency Data Integration
Leverage APIs and web scraping tools to gather price transparency data across health plans, collecting details
on provider costs, service rates, and transparency compliance.
Aggregates cost-related insights into the platform, enabling accurate provider comparison based on service
fees.
Actionable Performance Dashboard
A web-based interface displays real-time comparisons of provider performance metrics, such as quality
scores, patient outcomes, and cost efficiency.
Interactive filters allow users to narrow down providers by specialties, location, member feedback, and cost-
effectiveness.
Data Validation Algorithms
Machine learning algorithms validate provider data, cross-referencing it with member feedback and provider
visit frequency for accuracy.
Data is continuously updated to reflect any changes in provider quality, cost, and availability. | Two - Step Verification
Member Feedback System
Members are encouraged to provide regular feedback on provider quality and cost transparency through
token rewards or points.
The platform uses member feedback to improve data accuracy and inform cost comparisons between Web
providers. scraping Patient
feedback
| Step 2: Provider Recruitment and Network Optimization
Technology Components:
Provider
Advanced Web Scraping for Provider Recruitment
data
Web scraping technologies and APIs gather publicly available provider data across networks, pulling in
information on ratings, performance, and cost. Quality
Data from competitor networks are analyzed to identify high-value providers who could enhance scoring
network quality.
AI-Powered Recruitment and Optimization Engine
An AI model scores providers based on price transparency, quality ratings, health outcomes, and other Compliance Time, price
performance metrics, flagging those who would improve network quality. check location
Supports the creation of “narrow networks” by selecting providers who excel in cost-effectiveness and quality.
Reliability and Value Scoring Algorithm
A machine learning model assesses provider reliability and cost-effectiveness, generating a “value score”
that factors in quality, cost, availability, and network adequacy. scoring
Scores help network managers quickly identify high-value providers for recruitment and ensure network
optimization.
Recruitment Insights Provider Reliability Provider
Automated alerts notify network managers of potential high-value providers, changes in provider quality
scores, and cost discrepancies. score check recruitment
A recruitment dashboard displays provider comparisons, highlighting quality and cost leaders with visual
indicators for quick decision-making.
HiLabs
 Problem User Solution Technology Tool Wireframe Pitfalls

Network Management Tool List of Providers in a Health Plan

Provides a detailed list of all providers within a
selected health plan, enabling easy access to
provider information.

NetWise Network Hellen

Actionable Performance Analytics

Network

Amount Saved with Different Provider Health plan Mecare health list of providers Location Time saved in a Health Plan
Shows potential cost savings when choosing Compliance Calculates time saved by choosing certain
between providers, aiding in cost-effective Amount saved Time saved providers, optimizing member access and
provider selection. appointment efficiency.
Analyze

Recruit

Provider Ratings
Offers ratings for each provider based on Issues Positive ratings Negative ratings
member feedback, supporting informed
recruitment and retention decisions.
Ghost Networks
Help & Settings Displays the number of unavailable providers in
Network Adequacy Network Adequacy Compilance Breach Ghost Network the plan, helping to track and reduce ghost
Help centre
Displays the percentage of the network meeting network occurrences.
Setting
CMS adequacy standards, helping assess
compliance at a glance.

Netwise Product Vision

These features collectively support Netwise’s mission to link insurers, providers, and members, improving network quality, compliance, and member experience.
Each feature is designed to enhance visibility, streamline management, and drive proactive decision-making, creating a comprehensive platform for healthcare
network optimization.

HiLabs
 Problem User Solution Technology Impact Wireframe Pitfalls

Introducing NetWise Reliability Scores

Average provider engagement rates across domains, showing provider-
Health plan filter patient interaction levels.
Location Analysis Network Metrics comparison
County-based network comparison to allow to narrow down provider data, performance analytics,
Metrics on cost savings, time savings,
identify gaps and improve provider access and network adequacy information based on specific health plans.
and member sentiment for each network.

Time Filter
Product catalog of the MVP Date and time zone filtering for precise
Version performance and compliance insights.

NetWise Analyze Hellen

Mecare health

NetWise Compliance Hellen Network Comparison Reliability scores

quality Doctor Services

Network Provider Report Compliance

Analyze
Compliance Health plan Mecare health

Analyze Recruit Location Time Services

Recruit Issues Positive response

Health outcome Services Satisfaction

Issues Help & Settings

Help centre

Setting
Help & Settings

Help centre

Setting

Performance scores
Visuals for provider satisfaction by members, with county-provider pair
analysis.
Department Issues
Track and manage department-specific issues for streamlined resolution.

Compliance Reviews for different providers Discussion Hub

Officer reviews and member sentiment insights on waiting times and Member issue-raising, report access, and secure communication for problem resolution.
treatment stages.
HiLabs
 Problem User Solution Technology Impact Wireframe Pitfalls

Potential Pitfalls | Mitigation | Success Metrics

Primary Metrics
PITFALL RISK MITIGATION Compliance Rate: Percentage of providers meeting CMS standards (Goal: 95%+).
Data Accuracy: Increase in verified provider information accuracy (Goal: 90%+).
Gamification, personalized Reduction in Ghost Networks: Percentage decrease in unavailable or inaccurate providers (Goal: 80%+).
Low member verification
1. Member Engagement notifications, simplified High Reliability Providers: Percentage of providers with high reliability scores, with a goal to increase this
participation
feedback over time.

Encryption, access Secondary Metrics

2. Data Privacy & Data breaches, regulatory Update Response Time: Average time taken to verify/update provider data (Goal: <12 hours).
controls, audits,
Compliance penalties Member Satisfaction: Customer Satisfaction score (CSAT)
anonymization, training
Cost Savings: Reduction in costs associated with provider recruitment (Goal: 25%+).

3. Algorithm Bias
Inaccurate or unfair provider
scores
Diverse data, regular
audits, human oversight, | Future Enhancement
transparent scoring Provider Quality and Cost Forecasting
Implement forecasting models that predict provider cost and quality trends over time, helping insurers
Automated updates, make informed recruitment and retention decisions.
Frequent updates disrupt
4. Regulatory Changes regular reviews, adaptable
compliance Personalized Member Insights and Recommendations
framework
Offer insurers insights into member preferences and patterns, allowing them to tailor provider networks
based on member needs and improve satisfaction.
Compatibility issues, data APIs, data synchronization
5. Legacy System Integration Smart Notifications for Regulatory Updates
silos tools, phased integration
Develop a notification system that alerts users of new CMS and state regulations, ensuring timely
Transparent process,
adjustments to maintain compliance and network adequacy.
Low trust in scoring and
6. Trust Issues feedback options, data Integration with Telehealth and Virtual Care Metrics
verification
privacy assurance Track telehealth offerings and provider availability for virtual care, allowing insurers to build networks
with both in-person and remote care options for better coverage.
Slowdowns with network
Scalable cloud setup, load Predictive Analytics for Provider Value and Network Gaps
7. Scalability & Performance testing, database
growth Use predictive analytics to assess provider performance trends and identify potential network gaps
optimization
early, enabling proactive recruitment and adjustments.

HiLabs