健康计划网络折扣已经成为保险消费者——即自筹资金的雇主和经纪人——在选择保险公司时决定最低成本的首要财务指标. Although reporting your health plan’s network discounts is voluntary, 如果你想让你的计划在征求建议的过程中被考虑,这通常是必要的——运营商报告的折扣结果可能对业务增长和保持业务的能力产生重大影响.
折扣报告.¹ such as those supported by the Uniform Discount and Data Specification (UDS) process, tend to consistently show significantly favorable results for national carriers such as Aetna, 国歌, 和UnitedHealthcare. 品牌价值, 市场份额, and network size can allow these major health plans to attain lower payment rates with providers, they also employ dedicated teams with the sole focus of optimizing (i.e., strategically selecting) their claims data for these submissions and subsequent reports.
区域保健计划, despite the advantages of national carriers, have opportunities to compete—and they must in order to grow or maintain 市场份额. 较小的健康计划可以通过采用先进的数据分析和优化策略来增强和准确地报告其网络折扣. 通过向消费者展示本国航空公司的成本效益和价值,这将显著提高它们的竞争地位,并削弱国有航空公司的主导地位.
下面, 我们概述了与UDS提交相关的复杂性,并强调了健康计划需要做出的战略考虑,以优化其参与并准确代表其价值主张. 我们还讨论了使用价格透明度数据来对抗UDS的结果(或完全取代它们)以及利用这些信息的额外好处.
The UDS Process Overview
UDS已成为医疗保健行业分析供应商网络折扣的标准数据提交流程. 参与医保计划将大部分(但不是全部)索赔数据提交给保险经纪公司. These submissions are organized by service categories of inpatient, 门诊, 和专业, specifically including charges, negotiated allowed amounts, 和地区.
This data allows brokers to report on network discounts by service category 和地区 by payer, compared to all other health plans in the market that also participated in the submission. 其目的是为利益攸关方提供一套标准化的衡量标准,以评估不同健康计划的经济效益. 这些报告经常被经纪人用来指导自筹资金的雇主完成健康计划的选择过程. 在这些对话中,没有参与最终报告产出的保健计划往往被忽视.
While the discount metrics are easy to understand, UDS进程’s simplicity can be deceptive, glossing over the complexities of healthcare reimbursement and potentially misleading consumers. The submission is not properly regulated, 而且缺乏对不准确或虚假数据提交的处罚,这给解释和潜在的偏见留下了空间, particularly as the major insurance carriers largely influence the specifications. The skewed participation further complicates the landscape, as local health plan network pricing often seems unfavorable when it may very well not be.
通过积极地考虑UDS的长期参与战略,并有意地投资于提高分析复杂性, health plans can optimize their submission, better represent their value proposition, and position themselves to produce new metrics that augment UDS data.
Strategic Considerations for UDS Participation
A thoughtful and strategic approach is essential for health plans considering participation in UDS. While not participating may not be an option for many plans, 参与和报告不利的结果可能对计划的成员增长和保留数字更加有害.
To decide whether to participate, 对您的利用率数据和合同费率进行彻底的评估,以评估您当前的费率与市场竞争对手相比如何. 另外, 从不同角度评估费率和报销金额,以测试最准确和透明的衡量市场折扣的方法, with the possibility of these measurements returning a more favorable result than UDS reports.
Ultimately, your plan must balance several factors when weighing the decision to participate in UDS:
- 长期参与. 您的健康计划是否描述了参与后续数据提交的长期战略? If so, what factors will influence your continued engagement?
- Engagement with Benefits Consulting Firms. Which benefit consulting entities is your health plan considering for data submission, and what criteria guide your selection process?
- Exploration of Additional Exclusions and Adjustments. 您的健康计划是否希望调查特定的排除或调整,以改进其数据优化策略? 这些调整在多大程度上代表了你的健康计划在市场上谈判的折扣?
- Data Integrity and Representativeness. How does your health plan ensure that, while adjusting your data for submission, 维护数据的完整性和代表性,以准确地反映性能和价值主张?
- Regulatory and Compliance Considerations. 是否有任何与您建议的数据提交策略相关的法规或合规性影响,您应该意识到?
- Alignment with Price Transparency. Does price transparency data analysis align with results from previous UDS reports? Are the results more or less favorable for your health plan?
- Alternative Metrics and Messaging. Using publicly published price transparency rates and your client’s group utilization, 停止参与UDS的提交,而是分享价格透明度的结果是否更有利?
- Comprehensive Value Proposition. In addition to quantitative measurements of network pricing, does your messaging and communication capture your health plan’s entire value proposition?
UDS Process Participation Decision Tree and Other Options
Long-Term Strategic Option: Superseding UDS with Price Transparency
With the availability of both hospital and payer price transparency data, 健康计划和其他市场利益相关者现在有能力衡量和比较市场参与者之间的网络定价. 价格透明度文件包含确定设施和专业bet8娱乐场所的实际单位成本所需的实际协商费率信息. The publicly available price transparency data has the potential of being more accurate, 及时的, and transparent than UDS.
此外, 健康计划可以将价格透明度应用于集团使用数据,以计算集团特定bet8娱乐组合的网络成本. This can enable more accurate representations of a group’s care delivery costs between market payers. 另外, 开发一个模型来分析价格透明度数据,本质上将包括特定群体的使用信息,从而能够更细致地了解bet8网站备用的价格差异, 地区, 甚至是bet8娱乐类别——这在针对特定群体及其明确的优先事项的增长战略中可能非常有价值.
Transforming Challenges into Opportunities
总之, UDS进程, while a historical and widely used benchmark for evaluating health plan network discounts, presents both challenges and opportunities for health plans. National carriers have used their scale and dedicated analytical teams to optimize their submissions, often overshadowing 地区al players. 然而, 对先进数据分析和优化策略的投资为区域健康计划提供了一条可行的途径,以提高其竞争定位并准确报告其网络折扣. Strategic considerations—including long-term participation, refinements to data submissions, 对价格透明度的理解对于健康计划准确地代表其真正的网络价值主张至关重要.
By embracing these strategies, health plans can enhance transparency, 确保数据完整性, and better communicate their comprehensive value proposition to stakeholders, potentially reshaping the competitive landscape in their favor.
Looking to optimize your health plan's UDS participation? 联系 our Payer bet8娱乐 team.
¹报告由健康保险经纪公司通过汇总特定市场中参与保险公司提交的折扣数据生成.
编辑:Matt Maslin
出版于2024年5月28日