The provider relations function most networks skip.

Network builds are focused on getting providers in. The contracting team is measured on how many contracts are executed. The credentialing team is measured on how many providers are credentialed. Those metrics are right for a build. They are the wrong metrics for a network that is trying to stay intact over time.

After go-live, the most important network management activity is not contracting — it is retention. And retention is the product of the provider relations function, which most plans either don't have or have chronically underresourced compared to their contracting teams.

What provider relations actually does

Provider relations is the ongoing service relationship between the plan and participating providers. It has four core functions:

Issue resolution. When a provider has a claims problem, a billing question, a credentialing issue, or a member dispute, provider relations is the first escalation point. The speed and quality of issue resolution is one of the primary determinants of provider satisfaction — and provider satisfaction is correlated with retention.

Communication and education.Benefit changes, prior authorization policy updates, formulary changes, new care management programs — providers need to understand what is changing in the plan and how it affects their patients. Provider relations is the channel through which this communication happens. Plans that don't have a reliable communication channel with providers find that providers operate from outdated assumptions about plan rules, which generates more issues and more friction.

Performance reporting. For plans with value-based care arrangements, provider relations is often responsible for sharing quality and utilization reports with providers — explaining what the data means, what the financial implications are, and what the plan expects from the provider to maintain good standing in the arrangement.

Relationship maintenance. Periodic outreach to high-value providers — annual check-ins, contract review meetings, notification of upcoming renewals — that maintains the relationship before it becomes a problem. Providers who hear from the plan only when something is wrong have a different view of that relationship than providers who have a consistent, low-drama touchpoint throughout the year.

The CMS Star Ratings connection

CMS Star Ratings for Medicare Advantage plans include measures that depend on provider cooperation: HEDIS measures (which require providers to document and report clinical events), patient experience survey results (which reflect the care quality members receive from in-network providers), and medication adherence measures (which require provider-level engagement on polypharmacy and refill adherence).

A provider relations function that has built strong relationships with PCPs is a Star Ratings asset. PCPs who understand the plan's quality measures, who know their care gap reports, and who have a direct line to the plan for questions are more likely to close documentation gaps than PCPs who view the plan as an administrative burden. The delta between a 3-star and a 4-star plan sometimes lives in this relationship quality.

Contracting gets a provider into your network. Provider relations determines whether they stay, whether they recommend your plan to their patients, and whether they close your quality gaps.

Staffing the function correctly

Provider relations staffing is typically calculated as a ratio of provider relations representatives to participating providers. A reasonable starting point is one representative for every 300 to 400 participating provider organizations — not individual providers, but practice groups. A large multi-specialty group practice counts as one relationship even if it has 50 providers.

The representative should have enough clinical knowledge to speak intelligently about plan benefits, PA policies, and quality measures — but the job is primarily a relationship job, not a clinical one. Candidates who have worked in medical billing, practice management, or health plan operations tend to have the right background.

Geographic proximity matters. A provider relations representative who covers a region and can make in-person visits builds stronger relationships than one who only works by phone and email. Not every interaction needs to be in-person, but the capability to visit high-value providers or to handle a sensitive relationship issue face-to-face is worth resourcing.