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The NetMinder Blog

TPAs move beyond claims and eligibility

Posted by Laura McMullen on Thu, Jun 11, 2015

Large employer groups, unions, associations, and other plan sponsors are all looking for ways to minimize healthcare costs. Historically, one way is to self-fund to keep the administrative costs low and allow for customization of benefits offered. One of the ripple effects of the Affordable Care Act is that smaller groups are investigating self-funding as well. When groups self-fund, they commonly turn to third-party administrators to provide the services and expertise needed to establish and maintain the plan.


Third-party administrators and cost management experts work on behalf of employers and other groups to keep claims costs low. In addition to reporting on claims, eligibility, utilization, and other dimensions to help employers manage costs, they also aggregate and manage networks.Using supplemental networks can extend healthcare benefits to employees who don’t work in centralized locations and improve employee morale.

In 2013, Business Insurance ranked the largest TPAs that specialize in employee benefits. The top five were:

Third-party administrators commonly re-price claims by recalculating billed medical charges based on the rates and rules a PPO has negotiated with supplemental networks. They also directly negotiate with providers to ensure that all claims are discounted. These networks are often a combination of risk and non-risk PPOs, depending on the plans that are being offered to the group’s members. When there is a combination, it is important to make sure that all providers are properly contracted to offer discounts to members.

Another way that TPAs factor into the changing network landscape is to provide the claims administration, eligibility management, and other back office functions hospitals and health systems need when they start to sell to groups and individuals. This has become an important service in removing the barriers for new entrants into the healthcare market.

How can you leverage your TPA relationships to expand your sales and/or network reach?

Tags: health insurance, Affordable Care Act, health reform, consumer choice, employee benefits, third party administrators, TPAs

The impact of integrated health care delivery systems is growing

Posted by Laura McMullen on Thu, May 28, 2015

Hospitals have always had informal networks of nearby physicians with admitting privileges as well as staff physicians. And some hospitals and health systems, particularly those that self-insure, have long required employees to access care within their organization to help control costs. With a new set of incentives in the Affordable Care Act that encourage providers to focus on outcomes instead of activity, these practices came together to reduce the barriers to entry in the health insurance industry and create new entities that compete for premium dollars.

Cutting Out the Middlemen

hospitalLarge hospitals and local or regional health systems have formed insurance companies that sell plans to employer groups and individuals, i.e. North Shore – Long Island Jewish Hospital’s CareConnect or UPMC in western Pennsylvania. Dr. Kenneth L. Davis, CEO and president of Mount Sinai Health System in New York, said, “Inevitably the large systems are going to move to take part of the premium dollar,” in an article in the Fiscal Times after the 2014 Health Care Forum in Washington, DC, sponsored by The Atlantic. He went on to discuss the importance of “retaining more and more of the health care premiums paid by consumers is essential to providing a full spectrum of care.” For example, St. Luke’s Hospital, part of the Mount Sinai Health System, lost $14 million in its psychiatric program in 2013 and needs to be subsidized by revenue from other parts of the system. Offering insurance coverage is another way to do that.

Partnering to Compete

Some insurance companies own hospitals, other facilities, and physician groups which are included in their networks, for example Kaiser Permanente or Willamette Dental Group. Others choose to create new companies such as the joint venture between Anthem and seven Southern California hospitals when they formed Vivity Health Plan. Vivity is priced below Anthem’s standard HMO plan and includes the big academic medical centers consumers want access to, according to the LA Times. This new market entrant could take business away from Kaiser Permanente in the large Southern California market.

Too Big to Fail?

Another approach is for hospitals to merge. There were 95 hospital mergers and acquisitions in 2014, according to The ObamaCare Effect: Hospital Monopolies in the Wall Street Journal. Two acquisitions are being challenged in state court:

How does this trend play out in your network? Does hospital consolidation make it easier to set up a narrow network? Or is this an opportunity to add more locations and providers through the physician groups that are included in integrated health care delivery systems?

Tags: health insurance, narrow networks, Affordable Care Act, health reform, consumer choice, insurance companies

Changing Supply and Demand for Eye Doctors

Posted by Laura McMullen on Thu, Sep 11, 2014

Recently, the American Optometric Association and the Association of Schools and Colleges of Optometry, along with a number of vision industry leaders, commissioned the Lewin Group to conduct a study of the eye care workforce and create a computer model to continuously study supply and demand for eye care providers. AOA and ASCO leaders called the study “the most ambitious, comprehensive and forward-looking study of eye care supply and demand ever undertaken” in the release announcing the study. To get the National Eye Care Workforce Study go to (registration and fee required).

The study reports the same three factors that are driving demand for overall healthcare services are affecting the demand for vision care services:

  • The U.S. population is aging and its vision is deteriorating.
  • Diabetes is more prevalent than ever.
  • The ACA expanded the health insurance market and required vision coverage for children.

eye drThe National Eye Care Workforce Study reports an oversupply of optometrists and ophthalmologists through 2025. However, other experts frame a shortage.

One interpretation of the current market shows the supply of eye doctors is growing to meet the increased demand:

  • The supply of eye doctors is increasing. Three new optometry schools graduated their first classes in 2013 and another one will open in Kentucky in 2016. Every year 1,350 new optometrists graduate while 420 retire, according to a presentation Richard Edlow, OD, gave at the Integrated Ophthalmic Managed Eyecare Delivery program in April 2013. Some eye doctors postponed retirement until the U.S. economy rebounded, so the retirement rate will increase as the recovery continues.
  • Eye doctors could see more patients and keep their current schedules. Optometrists surveyed by the Lewin Group as part of the study reported that they could increase patient capacity by 32%, or 933 visits, annually without adding hours or days to their schedules.

Another interpretation shows that supply shortages are on the way while demand is growing:

  • More women are becoming eye doctors. “Fifty percent of ophthalmology residents are female, and 64% of optometry graduates are female,” Dr. Edlow said in his presentation. “Every study indicates that women work about 85% of a full-time employee. If we take this into account, we have 51,000 eye doctors, and we’re going to need 65,000.”
  • Eye doctors are working fewer hours. Most work 40 hours weekly as opposed to 50-60 hours weekly in the past.

The National Eye Care Workforce Study provides a snapshot of the current situation overview and also created a computer model to evaluate the workforce at future points in time. As time goes on and other factors come into play, the supply and demand picture will ebb and flow.

According to NetMinder, the industry standard for vision provider network comparisons, managed vision networks continue to grow, indicating strong demand from consumers and employers for access to vision care.

What do you see in your business?

Tags: NetMinder, vision market, Vision insurance, ACA, consumer choice, network comparisons, vision networks

UnitedHealthcare Plans to Expand Exchange Presence

Posted by Laura McMullen on Tue, Aug 12, 2014

UnitedHealthcare is betting that the health insurance exchanges are sustainable for the long-term, Kaiser Health News reported in July in a post titled Biggest Insurer Drops Caution, Embraces Obamacare.

What’s behind this decision?

  • understandingtheaca resized 600The marketplaces look viable, even without some of the government safeguards like risk-sharing and reinsurance support that will end after the first few years.
  • The pricing is clearer. With six months of claims experience from millions of people, UnitedHealthcare believes they can accurately rate their products.
  • The regulations are in place. Many of the pending lawsuits have been decided.
  • Consumer behavior is more certain. Even with all of the delays and challenges during the initial implementation of the federal exchange, millions of transactions have been completed and UnitedHealthcare believes “there’ll be some shopping, even though people don’t have to shop,” according to Jeff Alter, head of UnitedHealthcare’s employer and individual insurance division. “The natural consumer play of an exchange is going to cause a shopping experience.”

Does UnitedHealthcare’s entry change anything about your exchange strategy? Is this an attractive market for starting or expanding an insurance company?

Tags: health insurance, Affordable Care Act, healthcare reform, ACA, healthcare exchanges, consumer choice, Obamacare, insurance companies

New Whitepaper Clears Up Changing Vision Market

Posted by Aaron Groffman on Mon, Jul 01, 2013

Clearing up the Vision Market white paperVision insurers, medical insurers and insurance brokers will have a significant opportunity in the coming years as the growing market and changing make-up of vision care delivery impact vision care plans.

Vision care products and services are delivered at more than 47,000 U.S. optical locations, ranging from sole practitioners to mass merchandisers.  The market includes independent eye care professionals (ECPs) and retail chains. Market share indicators and loyalty metrics, such as the Net Promoter Score, show that consumers prefer ECPs for exams, but they more often choose retail chains for frames, lenses and contacts.

It’s clear from consumer purchasing preferences that managed vision care plans will need to include a combination of ECPs and retail chains in their provider networks to service the preventive and routine vision care needs of their clients.  The question is: what’s the right balance? 

To answer this question for your company, you first need accurate provider network data. Gathering and maintaining this information on your own can be expensive, time consuming, and subject to inaccuracy. The good news is we can help. Tracking more than 250 networks from national, regional and local vision, medical, dental, and behavioral plans across the country, NetMinder gives payers, brokers and consultants an objective, consistent, validated source of provider network data to use as they guide their customers in making smart employee benefit decisions.  

Download our new whitepaper, Clearing Up The Vision Market, to learn more about how the vision market is changing and what these changes mean for your company.

Tags: network providers, vision market, Vision insurance, consumer choice

Are Independent Eye Care Professionals Getting Their Share Of Market Growth?

Posted by Aaron Groffman on Tue, Jun 04, 2013

Vision care products and services sold at U.S. optical retail locations increased 5.8% from $28,624 million in 2011 to $30,287 million in 2012, as estimated by The Vision Council’s VisionWatch report. The nation’s top 50 optical retailers, representing 1 out of 5 retail locations, account for close to 27% of the total vision market, according to Vision Monday’s 2013 Top 50 U.S. Optical Retailers report and ranking.

VisionMonday 20130524Smaller retail chains, defined by VisionWatch as those optical retailers with 4 or more locations, accounted for 29% of the market while representing only 13% of total locations, according to the most recent NetMinder update.  Independent optometrists (eye care professionals, or ECPs, with 1-3 locations) account for 2 of every 3 retail optical outlets and control the largest share of the market.  In spite of their significant presence, ECPs’ market share is only 45%.  Why are ECPs’ revenues per location lagging the chains?  One reason may be that consumers gravitate to ECPs for the smaller, exam portion of the market, while preferring retail chains for the faster growing, more lucrative materials (frames, lenses, and contacts) segment.  

What does this mean for ECPs going forward?  Will they become marginalized by the big chains like so many other industries?  Or will their high-touch approach preserve their market position?

Tags: optical retail, sales, Vision, Vision insurance, consumer choice

Consumers Seek Real Data Online for Health Decisions

Posted by Aaron Groffman on Wed, Oct 31, 2012

Healthcare reform is not only changing the way individuals buy health insurance, it is also changing the way insurance companies will have to market their products. Many insurers are starting to experiment with direct-to-consumer marketing, hoping to reel in Medicare beneficiaries as well as those in the under-65 crowd who will soon be entering the market for individual policies. Developing a strong sales strategy backed by solid data will help you edge out competitors and win customers who are looking to make informed decisions.

Under the Affordable Care Act, individuals without medical insurance will pay an annual penalty starting at $95 in 2014 and increasing to $750 in 2016. That means millions of uninsured Americans will flood the health insurance market, and competition among insurers will continue to intensify.

How will you reach these potential customers? Start by providing the information they are looking for. About 60% of U.S. adults (80% of Internet users) look online for health information, according to a 2010 study by the Pew Research Center. A more recent study by Cybercitizen Health suggests that number may now be as high as 73%. You can influence and empower potential customers by arming them with comprehensive network comparison data that demonstrates the strength of your products.

Savvy consumers expect choices, and they want to make educated decisions about their healthcare. Although some insurance products are complex and difficult to explain online, using the internet and other direct sales channels strategically can boost your business.

State and federal health insurance exchanges will make it even easier for individuals to research and compare plans online before deciding on the best medical, dental and vision options for their needs. What kind of information are you providing to these potential customers, and which sales tools will you use to capture leads?

Tags: health insurance, Affordable Care Act, Healthcare, healthcare reform, consumer choice





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