81 / 537
Employer Group ABC
Incurred:
Apr 2014 thru Dec 2015
Paid:
Apr 2014 thru Mar 2016
18
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Page
3.1.1 Network utilization and contract discounts
Table 3.1.1 details in-network (Par) and out-of-network (Non-Par) costs, ranked by plan paid, for the various
networks used by your plan participants. This analysis also provides a comparison of discounts for the top ten
participating networks. Most benefit plans utilize a provider network where providers have agreed to accept lower
reimbursements in return for inclusion on a preferred provider list. Some out-of-network utilization is expected;
examples are members seeing a provider while away from home (out-of-area claims), or seeing an out-of-network
provider for an urgent or emergent healthcare condition. Out-of-network claims result in higher than expected claims
expense for the service provided. A high incidence of out-of-network provider visits is usually an indication that there
are access issues. These access issues can be impacted through network restructuring. Improved in-network usage
can be accomplished by limiting coverage for out-of-network services.
Table 3.1.1 Carrier Discounts and Network Utilization
19
Network
Total
Claims
Billed
Claims
Allowed
Claims Paid
Employee
Contribution
Network
Discount
% Discount
Network - 440000608
$95,778,181
$39,957,421
$39,143,769
$6,258,957
$49,343,650
51.5%
Network - 440000605
$100,187,039
$37,426,006
$32,689,413
$4,736,593
$41,670,889
41.6%
Network - 440000596
$44,311,569
$18,934,122
$18,855,775
$1,210,010
$10,297,120
23.2%
Network - 440000601
$37,044,040
$13,645,974
$13,025,885
$1,929,002
$16,336,672
44.1%
Network - 440000158
$26,892,486
$11,546,941
$11,457,568
$780,285
$14,222,706
52.9%
Network - 440000602
$21,803,270
$8,132,633
$7,931,071
$895,704
$9,892,959
45.4%
Network - 440000613
$6,887,200
$2,756,779
$2,643,026
$23,558
$4,130,421
60.0%
Network - 440000614
$3,755,703
$2,950,112
$2,482,246
$318,874
$805,625
21.5%
Network - 440000586
($46,758)
$30,912
($14,246)
$18,509
($129,117)
276.1%
All Other Par
(In Network)
$0
$0
$0
$0
$0
0.0%
All Non-Par
(Out Of Network)
$15,700,220
$7,624,470
$6,934,887
$1,976,699
$3,664,514
23.3%
Total
$352,312,949
$143,005,369
$135,149,394
$18,148,192
$150,235,439
42.6%
19
Note:
Refer to Table 5.2.6 in Appendix 5.2 for network summary.
Source: Medical Intelligence : Network Utilization Module / Discount