This method of network analysis correlates historical provider utilization and claims experience for a group of employees to the providers in a different network. If you assume that a population will utilize the same set of providers at the same frequency, you can estimate the amount of future utilization that will be in-network. Disruption Reporting is also used as a predictor of future financial experience, with more in-network claims (at a discount) resulting in lower overall claims expenses.
The utilization or claim file required for this method of analysis must include demographic data for each utilized provider, to determine if that provider is in the prospective network. Ideally it would also include quantitative statistics on how much treatment each provider performed, such as:
- Submitted claims (number and/or amount)
- Paid claims (number and/or amount)
- Number of procedures performed
- Number of patients treated
This type of utilization or claim file is generally only available when the company requesting it has at least 200 employees enrolled in that benefit plan.
There is tremendous variation in the format and quality of the utilization and/or claim data files that are included with requests for disruption reports. Unfortunately, it is very common for key provider identifiers to be omitted:
- Tax Identification Number (TIN)
- National Provider Identifier (NPI)
- State license numbers
In addition to the variation in the utilization and claim data files, there is a tremendous amount of variation in the matching criteria used when these reports are produced. When some networks use looser criteria than others, employers and employees don’t get a clear picture of network access.