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The NetMinder Blog

If You Think All Provider Networks Are Basically The Same, Think Again

Posted by Susan Donegan on Thu, Oct 19, 2017

After years of insurance companies and PPOs building and maintaining provider networks, the prevailing wisdom is that “all provider networks are basically the same.” A closer look at the composition of provider networks reveals something very different, however.

A comparison of two well-known, established provider networks in Florida shows that, while they both have almost the same number of access points (provider locations), the overlap between the two networks is only 47%. More than half of the access points in each network are unique to that network.comparison similarly sized networks.jpg

In order to better understand the differences between these two networks, we need to drill down to the specialty level. As you can see in the chart below, both networks have basically the same composition of Primary Care, Medical Specialists, and Surgeons. However, they vary significantly in other specialties such as Dental and Vision, Nursing, Therapists, and Behavioral Health.


It’s important to know which specialties are included in a provider network in order to be able to make an accurate, fair comparison.

Download our whitepaper, All Provider Networks Are Not Created Equal to learn how to use network data to demonstrate your competitive advantages for a specific client's needs.

Tags: network comparison tool, provider networks, network comparisons, provider directories, access points, provider network, provider locations

4 Ways to Measure Network Strength

Posted by Susan Donegan on Thu, Sep 14, 2017

The health insurance industry has developed a spectrum of network analysis tools to demonstrate a network’s breadth and depth, and to differentiate between networks.There are 4 common methods of network analysis widely used to evaluate health-related insurance products today. We visualize this spectrum as a pyramid to show how frequently the analysis is used and how specific the information is to each company. As you ascend the pyramid the frequency of availability decreases but the knowledge gained becomes more specific and as a result is more valuable to the overall assessment of the networks under consideration.4 ways to measure network strength.jpg

For example, at the bottom of the pyramid, measuring network size is fairly easy and is used in almost every analysis; it’s not very specific to a particular client or prospect. At the top of the pyramid, re-pricing the claims of the incumbent carrier is more difficult to do because it requires more data and cooperation from the prospect and the incumbent, therefore it’s done less frequently. However, when done, it’s very specific to the prospect’s situation. 

Download our whitepaper, The Network Analysis Pyramid for an overview of the most widely used methods to analyze provider networks.

Tags: compare networks, health insurance, network comparison tool, data analysis, network data, provider networks, repricing analysis

Studying the Accuracy of Provider Directories

Posted by Laura McMullen on Thu, Jul 27, 2017

Many people have had this experience – you’re looking for a new healthcare provider in your insurance plan’s directory and when you call, that doctor (or dentist or optometrist) doesn’t work at that location any more or the office isn’t accepting new patients. So you move on to the next name on the list and keep calling. As market forces, government regulations, and rising costs combine to focus more attention on every aspect of the health insurance industry, two recent initiatives examine provider directory accuracy.


CMS Online Provider Directory Review

In a previous post, we shared the preliminary findings from a CMS project designed to assess provider directory accuracy. CMS released the final report which confirmed that 47% of the 5,832 provider records reviewed in Medicare Advantage networks had at least one deficiency and listed the names and results of the 54 health plans involved in the audit along with the compliance actions taken. Fierce Healthcare summarized the results here.

AHIP Provider Directory Initiative

Between April and September 2016, AHIP executed a large-scale project to evaluate a variety of ways to update directory information. This issue brief summarizes the project including background on the vendors, methodology, and results of an independent evaluation by NORC at the University of Chicago. A blog post from March 2017, What It Takes to Improve Provider Directories, discussed the findings and offered potential solutions in actions that could be taken by providers and networks:

  • Provider side: enforce contractual requirements and offer incentives to providers
  • Network side: use multiple channels and media to connect with providers such as email, phone, mail, fax, and provider one source to update data for multiple plans

The prevalence of inaccurate data that CMS found and the low response rates plus lack of information about the importance of updating directory information underscore the complexity of maintaining this information. “The root cause of the problem isn’t the directories themselves; it’s the underlying data. Capturing, storing, and retrieving provider data has always been a complex process,” writes Mark Martin, Availity’s director of payer solutions, provider data management, and Dianne Wagner, senior director, provider engagement and enablement at Guidewell, in Managed Healthcare Executive.

The importance of accurate provider directories to the whole healthcare industry – consumers find providers and make appointments easily, providers earn the advertising and publicity benefits of inclusion in provider directories, and networks improve customer satisfaction, compare provider directories, and avoid compliance actions – make fixing this problem a chronic priority.

What steps are you taking to improve the accuracy of your provider directory?

Tags: health insurance, provider networks, provider directories, healthcare system, healthcare providers

Network Analysis with Disruption Reporting

Posted by Susan Donegan on Fri, May 19, 2017

Network_Analysis_Pyramid_Cover.pngThis 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.

Download our whitepaper, The Network Analysis Pyramid for an overview of the most widely used methods to analyze provider networks.

Tags: disruption reporting, data analysis, provider networks, claims data, repricing analysis, discounted fees, network analysis

The Role of Repricing Analysis

Posted by Susan Donegan on Thu, May 11, 2017

Network_Analysis_Pyramid_Cover.pngRepricing Analysis is the least frequently available network analysis method by a wide margin, but when it is available, it is a very good predictor of future financial experience. Repricing Analysis begins with Disruption Reporting, but goes a step further. Once an in-network provider that matches a record in the claim file is identified, the discounted fee arrangement under which that provider is contracted is applied. For out-of-network providers, the reasonable and customary (R&C) charges for the area are applied. Reports from different networks are compared based on the overall cost of the claims for all providers (in-network and out-of-network) and the amount of savings each network would achieve.


Because Repricing Analysis is an extension of Disruption Reporting, all of the considerations that affect Disruption Reporting affect Repricing Analysis in the same way.

In addition, Repricing Analysis requires an extremely detailed claim file. In order to apply the discounted fees, the file must include a record for each procedure performed by each provider.

Are you using repricing analysis to help win new business and save retention threats? 

Download our whitepaper, The Network Analysis Pyramid for an overview of the most widely used methods to analyze provider networks.

Tags: disruption reporting, data analysis, provider networks, repricing analysis, discounted fees

CO-OPs and Integrated Health Care Delivery Systems Exiting Insurance Market

Posted by Laura McMullen on Wed, Dec 21, 2016

ACA.pngOne of the intended effects of the Affordable Care Act was to open up the insurance marketplace to new competitors. In 2015, we examined CO-OPs and integrated health care delivery systems to learn more about their business models and positioning. Both types of companies are leaving the market now without having reached the critical mass of members and premium needed to compete against the larger, more established insurance companies operating in their service areas.

Here are the stats on CO-OPs, according to

  • 5 of the 23 CO-OPs that were originally chartered under the Affordable Care Act will be operational in 2017.
  • 2 of the remaining CO-OPs are working with outside investors to stay in business: New Mexico Health Connections is currently profitable and working with Raymond James, a NY investment firm, to raise a substantial amount of funding to continue operations and Evergreen Health in MD is working with private equity investors to transition from a non-profit CO-OP to a for-profit entity.
  • CO-OPs owe more than $130 million to the 2015 Affordable Care Act risk adjustment program that distributes payments from health insurers with lower-risk enrollees to health insurers with higher-risk enrollees. This program was created “to prevent insurers from designing plans that appeal only to healthy enrollees, and to ensure that premiums reflect benefit levels, rather than the overall health of a plan’s enrollees.”

Integrated health care delivery systems are winding down their operations too, as reported in the Denver Post.

  • Catholic Health Initiatives, Tenet Healthcare Corp., WellStar Health System (GA), and Piedmont Healthcare (GA) have all sold or shut down their insurance operations after steep losses.
  • High start-up costs to compete against well-established carriers and low membership contributed to their decisions.
  • Ascension Health (St. Louis) and Northwell Health (Great Neck, NY) remain in the insurance business.
  • “McKinsey & Co. said in a 2015 report that while hospital-owned insurers covered just 8% of the nation’s insured, 20 of those 107 insurers accounted for two-thirds of that total.”

How do these plan shut-downs affect your business? Are the providers in these networks already in your networks? Do you want to add them?

Tags: health insurance, Affordable Care Act, ACA, provider networks, health insurance co-ops

Which Specialties Are Most Important to Your Network?

Posted by Laura McMullen on Wed, Nov 30, 2016

The Pareto Principle says that, for many events, 80% of the effects can be attributed to 20% of the causes. This is true about the cost of healthcare both from the demand side where most of the need for services is in the last years of life and from the sickest part of the population and from the supply side where most of the physician expense is concentrated among several specialties. (Inpatient treatment and specialty drugs are large components of medical spend too but since NetMinder is all about networks, we’re going to concentrate our analysis on physician specialties.)

We analyzed five national commercial medical networks using NetMinder. The 10 specialties that make up the bulk of these networks are counseling, family practice, general practice, internal medicine, nurse, ob-gyn, optometry, physician assistant, pediatrics, and social work. They represent 55-67% of each network. It’s no surprise that primary care physicians make up the bulk of these networks – everyone needs one, even when there’s no gatekeeper, because consumers generally don’t know exactly what’s wrong when they go to the doctor. Another reason for this might be that competition for patients in some markets is fierce leading some types of providers such as optometrists, counselors, and social workers to look for ways to market their practices.

However, these specialties are not among the top-earning specialties.

In 2014, the New York Times reported the top-earning medical specialties are orthopedics, cardiology, anesthesiology, radiology, dermatology, plastic surgery, urology, gastroenterology and ophthalmology. The article goes on to say “Physicians in those fields typically earn more than $350,000 annually, according to American Medical Group Association, a trade organization. In many specialties, income has risen more than 10 percent since 2011, according to Medscape, a Web company that follows the industry.” The top-earner specialties make up 12-21% of the commercial medical networks we analyzed.

Two of them – internal medicine and family practice – are in the top 5 for Medicare cost.

In 2012, Bloomberg analyzed Medicare payments to individual providers by specialty. This list represents 60% of expenditures, and 34-62% of the commercial medical networks we analyzed.

specialty chart.jpgSource: Centers for Medicare and Medicaid Services, Bloomberg

Without network constraints and as the largest insurer, it stands to reason that the specialty types Medicare pays the most will be similar to the specialty types that earn the most. Five specialties – orthopedics, cardiology, radiology, dermatology, and ophthalmology – are in both lists. These five specialties represent 10-15% of the commercial medical networks we analyzed.

Take a look at our whitepaper, All Provider Networks are not Created Equal, for more about how to take the composition of a network into account when you are comparing networks.

Networks are built to meet the needs of the members who use them so we’d expect variation in the types of specialties that make up the bulk of each one. Do you have enough of the right type of providers in your network to support the demand? Which specialties are over-represented? Which are under-represented?

Tags: health insurance, provider networks, medical networks, medical specialties

10 Key Data Points for Conclusive Network Comparisons

Posted by Laura McMullen on Fri, Jul 15, 2016

Critical Capabilities for Better Network Comparisons

ten_key_data_points.jpgProduct, sales and network teams’ needs are deeply intertwined — and success for each team relies on the ability to find the edge against competitor provider networks. When high-level comparisons suggest networks are the same or no advantage appears, that’s your cue to dig deeper.

Based on our work with more than 50 healthcare companies (and their aggregate 4,500 users), we offer 10 metrics that are critical for making more effective comparisons — which ultimately means designing better networks and selling more effectively against your competition.

The “Must Have” Capabilities for the Three Major Counting Methods

When you compare networks, how you count really matters. Different comparisons return different results, and are useful for different purposes. Selecting the right comparison method is key to your network development strategy, and to helping clients make better decisions.

In most cases, you’re counting by access points, unique providers and unique locations. Take a look at our whitepaper, How You Count Matters as Much as What You Count, for tips about choosing the right counting method for your analysis.  

10 Key Data Points You Must Have

Let’s add an overlay to the capabilities that drive the three effective counting methods — 10 metrics that must be pinpointed for your network development and sales efforts to make meaningful comparisons:

  1. Which network has more unique providers?
  2. Which network has more access points?
  3. How truly similar are the networks you compared? (In other words, how many providers are in both networks?)
  4. How many of each specialty category does each network have?
  5. Based on member demographics, which specialties are most important in this situation? Which network has more?
  6. How many providers in each network are within an X-mile radius of the locations where your group lives and works? Your radius might be smaller for urban ZIP codes and larger for rural ZIPs.
  7. How many locations/provider are in each network? When this ratio is high, directory inflation could be present.
  8. How many providers/location are in each network? When this ratio is high, large practice negotiations could disrupt the network.
  9. Has the network grown or shrunk overall during the last year or six months?
  10. What type of recruiting activity has there been recently? Adding new providers or replacing providers?

If you cannot decisively answer the 10 questions above, you may be missing key opportunities in network development or sales. You would not be alone in this regard: many competitive network data providers exist, but most provide cosmetic ease of use at the cost of more flexible and powerful reporting options.

If you find your teams hamstrung in their quest to make more effective comparisons — and ultimately drive more profitable activity at every level of your organization — click here and get in touch with us. We’ll talk about a better way to find and capitalize on critical points of difference.

Tags: compare networks, data analysis, provider networks, network comparisons, network development

Claims Data Makes Provider Directories More Accurate

Posted by Laura McMullen on Thu, Jan 21, 2016

“About 70% of plans sold on the exchanges in 2014 featured a limited network, and their premiums were up to 17% cheaper than plans with broader networks, according to a study by consulting firm McKinsey & Co.”, reported Modern Healthcare in March 2015. In response to consumer complaints about narrow networks, network adequacy regulations set criteria for distance to providers; the quantity of providers in a network; and the inclusion of essential community providers in a geographic area and, beginning January 2016, fines for inaccurate data.

Accurate provider directories are a problem for all networks. Providers retire, sell their practices, change jobs, and die, just like everyone else. It’s difficult to stay on top of this information, especially if you have several networks and/or network partners. The credentialing process, where provider credentials are reviewed at least once every three years to evaluate their practice histories and qualifications, and self-reporting are the primary methods network managers use to update their records. A 2014 study published in the Journal of the American Medical Association Dermatology found that these methods aren’t working:

  • Among 4,754 total dermatologist listings in Medicare Advantage networks in 12 US metropolitan areas, 45.5% were duplicates in the same plan directory.
  • Less than half (48.9%) of the unique physician listings were reachable, accepted the listed plan, and offered an appointment.

The Department of Health and Human Services’ Office of the Inspector General found similar results when looking at Medicaid networks in 2014. When they surveyed 1,800 primary care providers and specialists, “35 percent could not be found at the location listed by the plan, another 8 percent were at the location but said that they were not participating in the plan, and an additional 8 percent were not accepting new patients.”

Some experts suggest improving the accuracy of provider directories by including only providers to whom you’ve paid claims within 12 months. “Since 2013, New Jersey health plans must attempt to contact any provider who hasn't filed a claim in 12 months. If a provider fails to respond in 30 days, the insurers must remove that listing. Since then, ‘the number of complaints has gone down,’ says Larry Downs, CEO of the Medical Society of New Jersey,” in “Insurers Race to Avoid New Fines” on

Overstated access has been a problem in dental PPO provider directories for several years; access points are growing twice as fast as unique providers and unique locations.


We’ve seen success using claims to verify locations where providers are practicing in our dental network analyses. In general, we find that about 75% of dental access points can be validated through claims analysis. Demonstrating clean data vs. your competitors is a definite advantage when selling your network to clients and brokers and also helps focus recruiting efforts, saving time and money. Learn more about our approach in our whitepaper Are Dental Provider Directories Overstated?

What steps are you taking to ensure accurate provider directories? How do you figure out which providers are really available in your competitors’ directories?

Tags: narrow networks, provider networks, dental PPO networks, medicare advantage, provider directories, claims data

4 Network Metrics to Help Make Your Network Stand out from the Crowd

Posted by Laura McMullen on Wed, Aug 26, 2015

In a previous post, we talked about the four types of network analysis the employee benefits industry developed to measure and compare provider networks. Each type of analysis is valuable at different points in the selling process:

  • Early stages to convince groups and brokers to consider a network
    • Network counting: measure the quantity of providers in each network
    • Accessibility analysis: correlate network provider locations to employee home and work location
  • Later stages to demonstrate savings and convenience for members
    • 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
Apples_ResizedBut not every selling situation calls for a report. Sometimes all you need are a few metrics to catch someone’s attention so that you can have a larger discussion about why your plan is a good option for a group. Here’s a look at four network metrics that can help you make your network stand out:
  1. Counts. Access points, unique providers, or unique locations? Choosing the right counting method can make all the difference in how your network is perceived. If you have fewer access points and fewer locations/provider you might find that a unique provider count presents a better picture of your network than access points.
  2. Locations/provider. Use the NetMinder Snapshot to find this metric or compare access points to unique locations to see how your network looks versus your competitors’ networks. A high locations/provider ratio can indicate directory inflation.
  3. Total change. The sum of adds and drops in a network during a specified time period. Use this metric to showcase a geographic area – deliberately adding and removing providers to improve the network.
  4. Net change. The difference between adds and drops in a network during a specific time period. Use this metric to show growth or contraction over time.
    (Total change and net change are both available in the NetMinder Network Change report.)

In general, the process of comparing provider networks is the same whether you are comparing dental, vision, or medical HMO networks. However, each line of business has a few specific metrics to address unique situations. Here are a few that we use regularly:

  • PCPs/total providers. The percentage of a medical network that is primary care providers (usually internal medicine, general practice, family practice, OB/GYN, and pediatrics) is particularly important when evaluating a medical network. A lower percentage can result in longer wait times for members to get appointments. It also could indicate that different types of providers are identified as PCPs which could also cause disruption to members when changing plans.
  • ECPs/total providers. The percentage of a vision network that is eye care providers (optometrists and ophthalmologists) is a significant distinction. Consumers gravitate to ECPs for exams and retail chains for glasses and contact lenses so having a selection of both types of providers can increase member satisfaction.
  • Practicing providers and locations/all locations. The percentage of a dental PPO network that is practicing can make all the difference because directory inflation is common. NetMinder validates locations using claims data which helps focus recruiting efforts and clarify the network landscape.

When you tell your network story, which metrics do you use to support it?

Tags: compare networks, network metrics, health insurance, network comparison tool, disruption reporting, network change, provider networks, employee benefits





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