4.8 Provider Analysis
Claims Review includes four top level reports designed to simplify the task of identifying top providers, determine cost allocation, and measure physician vs. facility use.
Planwatch uses the term "Provider" to refer to any physician, facility, or product vendor that services the covered population; its use is not limited to medical practioners as is common in certain medical circles.
Top 30 Providers
The Top 30 Providers report lists the thirty most heavily utilized providers based on the total amount of sponsor dollars paid. The list includes the provider's name (obscured below), the total amount paid by the plan sponsor, and the percentage of total plan dollars:
Fields included in the table:
- # Charges ( Charge Count ): The number of charge lines processed (each claim may have multiple charge lines). More.
- Total Charge: Original total amount billed by provider before network discount or other types of savings are applied. More.
- Plan Paid: Total amount paid by plan sponsor.
- % Paid ( Plan Paid Percentage ): The percentage of original billed charges paid by the plan sponsor. More.
- % Usage ( Percentage of Usage ): The percentage of total dollars paid by the plan sponsor. More.
The bottom of the table includes total values for the providers displayed as well as paging capabilities so that additional provider information can be viewed.
Here we see that 76.88% of total plan dollars go to the first thirty providers listed.
Provider Cost Allocation Analysis
The Provider Cost Allocation Analysis report breaks down sponsor dollars between network and non-network facilities and physicians. This provides insight into the covered populations tendencies for provider and network utilization and can be used to determine the potential effectiveness of plan modifications that encourage network steerage.
The graph shows Network Facilities (dark blue), Non Network Facilities (light blue), Network Physicians (dark red), and Non Network Physicians (light red).
Facility and Physician Analysis
The Facility and Physician Analysis reports show the top fifteen most utilized providers in each category for both network and non-network activity. The list includes the provider's name (obscured below), the total amount paid by the plan sponsor, and the percentage of total plan dollars.
These reports are often useful in discovering providers that are not currently in a network.
See Also: The Facility and Physician Analysis reports are functionally similar the the Top 30 Providers report documented above.