A network’s reputation is an average. Your employees don’t get care at an average.
Two in-network hospitals in the same city can be paid very different amounts for the same procedure, and a network’s discount percentage says nothing about which one your people use. We push carriers and vendors for cost and quality data by provider, then read it against where your claims actually go.
The discount off billed charges is the least useful number in the proposal.
Billed charges are set by the provider and the discount is measured against them, so a deep discount off an inflated list price can still be the expensive option. We ask for the figures that show what the plan actually pays.
Allowed Amounts by Provider
The allowed amount is what the plan and the member pay together after the network discount. We ask for it by facility and by common procedure, because that is the number that moves your claims cost, and the discount percentage hides it.
Where Your Claims Go
A network can be inexpensive on average and costly for you if your employees concentrate at its highest-priced system. We map your claims by provider, so the comparison uses your utilization, not the carrier’s whole book of business. That is what network cost data is for.
Quality Signals That Mean Something
Readmissions, complications and appropriate-care measures by provider. We ask how each measure is built before we use it, which is why an honest gap in the data beats a star rating. Provider quality data belongs next to price in every network decision.
Published Price Files
Plans and carriers now publish negotiated rates in machine-readable files. We use them to check what a vendor tells us rather than as the answer, because on their own they are hard to read. Transparency in Coverage files are a starting point, not a verdict.
You are entitled to the data. Getting it is a contract question.
Group health plans may not agree to contract terms that restrict access to provider-level cost and quality information or to de-identified claims data. A clause that says the data belongs to the network is now a clause to strike, not accept.
The Annual Attestation
Plans attest by December 31 each year that their contracts carry no prohibited gag clauses. A carrier or vendor can submit on the plan’s behalf, but the plan still owns the answer, so we read the contract language before anyone attests.
Access Written Into the Contract
An attestation says restrictions do not exist; it does not make data arrive. We push for delivery terms: which fields, how often, in what format and at what cost, so the right to data becomes a report you actually receive.
When a Vendor Says No
A refusal is information about how the vendor prices. It becomes a factor at renewal and in any request for proposal, which is why we document the request and the answer instead of letting it drop. Access to your own plan data is a fair contract term.
Provider data earns its keep when it changes a network choice or a plan design.
Collecting cost and quality data is only worth the effort if something changes because of it. These are the decisions it usually informs.
Network Selection
When two networks look alike on discount, allowed amounts at the facilities your employees use often separate them. We put that comparison in front of you before the renewal decision, not after the first year of claims. Network cost data makes that difference visible.
Plan Design Steerage
Lower cost sharing at a high-value facility and higher cost sharing at an expensive one can move behavior without narrowing the network. The data shows which services have enough price spread to make that design worth explaining. Steerage works best with clear employee communication.
A Baseline for Next Year
We set a baseline by provider so the next year’s claims can be read against it. That turns a vague sense that costs rose into a finding about where, which is something a vendor can be held to. A provider-level baseline makes network costs measurable.
What employers ask about network data.
Is this only for self-funded plans?
Self-funded plans have the clearest claim to their own claims data. Fully insured employers can still ask for provider-level cost and quality information, and the answer shapes carrier selection even when the premium does not move right away. Network data helps either way.
Can a smaller employer get provider-level data?
Usually less of it. We ask anyway, because what a carrier will release to a smaller group is part of comparing carriers, and the published price files fill some of the gap. Asking is part of any carrier comparison for a smaller employer.
Won’t steering to lower-cost providers upset employees?
It can, which is why we lean toward design incentives before exclusions. The data tells you whether the savings justify the disruption; how you explain it decides whether employees accept it. Clear communication and fair incentives keep network steerage from feeling like a penalty.
Related guides.
HMO, PPO, EPO, POS and HDHP
How each plan type works, which fits which workforce and what offering several changes.
Emergency Room, Urgent Care or Telehealth
Steering care to the right place.
Narrow and Tiered Networks
How they cut cost and who they disrupt.
Send us your renewal.
We’ll tell you whether it looks competitive, where we see opportunity, and the five questions we’d put to your carrier. No cost, and no obligation to move anything.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents — two more if your group is 50 or more. Nothing else; every extra one is a reason to postpone.
An independent employee benefits consulting firm. We look at the entire benefits program — cost, plan performance, risk and administration.
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