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How does network leasing work in health insurance?

Posted by Laura McMullen on Thu, Mar 26, 2015

In a previous blog post, we explored the narrow network trend that began with HMOs and resurfaced on the federal and state exchanges from the Affordable Care Act. In that post we also touched on some of the new entrants into the health insurance market like co-ops and health system-based networks. This is the first of a series of posts that explores these new entrants and their network structures further.

healthinsuranceHistorically, insurance companies built and maintained their own provider networks. As the healthcare market changes, new network organizations have become more prevalent and visible and existing networks have been put to different uses. These network organizations can be categorized into six groups: network leasing companies; CO-OPs; TPAs and other cost management experts; discounters; hospitals and health systems; and accountable care organizations (ACOs).  Each of these categories has a slightly different perspective on managing provider relationships – some work closely with providers while others are at arm’s length – and it’s important to keep these differences in mind as you compare networks. This post takes a look at network leasing companies and future posts will examine the other types.

Network Leasing Companies

Many medical and dental networks use leasing partners to fill in service area gaps, meet network adequacy requirements, move into new markets, and grow their networks in general. There are two types of PPO networks that are available for lease.

Insurance companies take the financial risk for an enrollee’s medical costs and offer a network of providers who accept reduced fees for access to enrollees to control those costs. Staff at the insurance company recruit providers into the network and manage the ongoing relationships. When carriers have excess capacity in their networks, they sometimes decide to lease or swap all or part of the network to other companies. Lease arrangements earn additional revenue for insurance companies through monthly network access fees. Swaps fill in network gaps which can create a stronger sales advantage.

Examples of insurance company networks available for swap or lease:

Non-risk PPOs offer providers a fee schedule for covered services and then sell access to the network to other entities, i.e. insurance companies, employer groups, associations, unions, etc. The company offering the PPO doesn’t take the risk for the enrollee’s medical costs. The provider’s contract is with the network leasing company and the leasing entity is one step removed. The network leasing company receives a monthly network access fee for every person who can use the network, although other arrangements are possible. These arrangements are popular in medical and dental networks with standalone companies and carriers offering their networks for lease.

Examples of non-risk PPOs available for lease:

Vision networks are also leased as non-risk PPOs or offered under their own names by medical or dental carriers where the risk is taken by the vision plan. EyeMed and Block Vision are active in this space.

When leasing all or part of a network, it is important to make sure that all providers are properly contracted to offer discounts to members. When networks are “stacked,” offering multiple networks within a service area to achieve higher discounts, providers can be confused about which fee schedules are in effect. Confusion in the provider’s office can lead to member dissatisfaction if the wrong coinsurance or copay is charged which ultimately leads to lost business. When leasing, be sure your network team works closely with its counterparts in your lease partner’s organization.

How does network leasing fit into your business plan? Are you looking at new service areas? Do you have network adequacy requirements to meet?

Tags: network providers, Affordable Care Act, network leasing companies, dental PPO networks, insurance companies, vision networks, non-risk PPOs

Five Best Practices to Use Network Data to Grow Your Business

Posted by Darrin Hall on Thu, Jun 26, 2014

There are many factors employers consider when selecting an insurance carrier: price, benefits, service reputation and, to an increasing level of scrutiny, provider network. Positioning your provider network as the best fit for a client or prospect can make all the difference in winning the business.

Provider networks have to satisfy customers and members on multiple levels: 

  • Wide range of choices: multiple general and specialty providers are included in the network
  • Convenient to use: providers are located near home or work
  • Include popular providers and facilities: providers are the ones that members and their families want to use
  • Cost-effective: in-network providers offer meaningful discounts that reduce out-of-pocket expenses and claim costs

Because the provider network is hard to measure and so important to winning and retaining business, the industry has developed four types of network analysis:network analysis pyramid

  • Network Counting – measure the quantity of providers in each network
  • Accessibility Analysis – correlate network provider locations to employee home and work locations
  • Disruption Reporting – match historical provider utilization and claims experience for a group to the providers in a different network
  • Repricing – compare cost of claims for all providers (in- and out-of-network) if a different network were in place to the cost experienced in the current network

Download our whitepaper, The Network Analysis Pyramid, to learn more about each method.

Insurance companies and network leasing partners are both the source of the data in these reports and the consumers of the analyses during their sales processes. This dual role provides incentive to invest the resources needed to prepare and maintain network data so that they are in the best position to win new business.

So, what can you do to show your network in the strongest position?

Here are five best practices for managing your network data that will give you the best results in your network comparisons.

  1. Review your directory data regularly. Be sure that provider names, addresses, and phone numbers are up to date. Transparency in your reporting will be to your advantage in the long run.
  2. Check for duplicate records that can be consolidated, especially if you are stacking networks, since it can be hard to identify providers from the vendor network that are already in the carrier network.
  3. Adopt data standardization practices, particularly for numeric fields. For example, make sure leading zeroes on ZIP codes have not been dropped and replaced by the first digit of the ZIP+4. This is common in ZIP codes in New England, New Jersey, and US Caribbean territories.
  4. Consider including competitor network data in your analyses so that you understand your competitive position, predict results, and prepare for the future.
  5. For Disruption Reporting and Repricing, make sure that provider name data is properly parsed and address data is standardized. Use the same processes for claim and provider data files to give best chance of identifying valid matches.

Earning new business and retaining current customers are the lifeblood of every company. Improving your position by cleaning and maintaining your network data can make it easier to do both.

What process do you use today to manage your network data?


Tags: network providers, health insurance, network comparison tool, disruption reporting, network data, network management, network leasing companies, provider networks, insurance companies





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