Out of Network Spending: Get Insights Into Member Utilization

One of the biggest challenges in the benefits industry is how to incentivize member behavior. In this case study, we’ll look at how one Artemis Health customer used data to find and tackle out of network spending.

This customer wanted to better understand their dialysis spending to help members seek lower-cost, in-network treatment.

Dialysis treatments are costly for both members and payers. It costs on average $89,000 per patient per year according to the U.S. Renal Data System.

The challenge.

How do you positively impact spending without negatively impacting your member population? This is where Artemis comes in. Our proprietary data models and easy-to-use analytics tool helped this customer find savings on an expensive procedure while still offering quality care to members.

Tip: Out-of-network claims are “low hanging fruit” for benefits analysis.These costs are often preventable, and smart benefits teams will focus both on network steerage and ensuring their network is meeting members’ needs.

The solution.

The Artemis Platform makes complex analyses a snap. We compared costs, member risk scores, utilization, and more with just a few clicks.

01   Artemis created cohorts. We utilized the Cohorts app to compare in-network and out-of-network dialysis patient risk scores.

02  Artemis calculated the cost. We broke out dialysis spending by age group, member type, month, average by member, sum, and more to give the customer a comprehensive view of their costs.

03   Artemis identified common out-of-network providers.

Our team broke down claims to the provider level, allowing the customer greater insight into the causes of their out-of-network costs.

“Our customer wanted to align benefits and member education when it comes to dialysis. The goal is to steer members to an in-network facility for savings that impact both the customer and their members.” —Leann Fletcher, Customer Success Manager at Artemis Health

The results.

The customer noticed a clear trend in their benefits data: both year-over-year costs and the number of out-of-network claims are rising. Armed with this information, the benefits team will audit network coverage and communicate through the carrier with members to help them choose lower-cost in-network dialysis services.