Network Leakage & Utilization Audit
The Challenge
The firm’s employees were frequently utilizing providers outside of the high-value network, leading to increased costs for both the plan and the members. There was no clear understanding of why this leakage was happening or how to direct members toward more efficient options.
The IMPACT
This lack of direction was diluting the effectiveness of the negotiated network rates and driving up the overall cost per claim. The employer felt their benefits package was losing its competitive edge as costs continued to rise without a clear strategy for containment.
The Strategy
We conducted a deep-dive audit to identify the sources of network leakage and the specific procedures where costs were highest. We then redesigned the plan incentives to make high-value, in-network providers the easiest choice for the members.
THE OUtcome
The audit and subsequent plan adjustments resulted in a significant increase in in-network utilization and a stabilization of the overall claim trend. This meaningful impact restored the plan’s financial health and provided a better experience for the employees.
Things Employers Should Consider
Network leakage is often a sign of a plan design that lacks clarity and direction. Employers must use data to understand member behavior and then provide the grounded guidance needed to help them make better choices. Efficiency is found when the plan’s incentives are perfectly aligned with the most high-value providers.