Payors / network performance
Steer Members to Providers Who Deliver
Cost, quality and access all live in the same claims. Ana scores every provider group against its contract and its peers, finds where members leave the network, and tells the network team where to steer and what to renegotiate.
Fixed scope: your top episodes and a year of claims, run inside your cloud.
Renew by Habit, or Contract on Evidence
- Provider scorecards rebuilt once a year for renewals
- Cost compared per claim, not per episode
- Leakage noticed when the out-of-network bill arrives
- Steerage by directory order
- Every group scored on cost, quality and access, monthly
- The same episode compared across every group
- Referral leakage traced to the referring provider
- Members steered to the groups that deliver
Compare the Same Episode Across Every Group
A claim-by-claim view hides the real spread. Ana groups claims into episodes — the surgery, the imaging, the rehab, the readmission — and compares the same episode across every group, with outcomes beside cost.
- Claims grouped into episodes, end to end
- Cost read beside quality and readmissions
- Adjusted for the members each group sees
What does a knee replacement cost us by group?
$18.2k to $41.9k for the same episode, with the same readmission rate.
- group a 18.2k
- group b 1.2× group a 21.0k
- group c 1.6× group a 29.4k
- group d 2.3× group a 41.9k
Follow Where Members Leave the Network
Leakage starts with a referral. Ana follows each out-of-network episode back to the referring provider and the reason — no in-network capacity, no appointment, or habit.
- Each out-of-network episode traced to its referral
- Capacity and wait times read beside it
- Referring providers ranked by leakage
Why did member M-50731 see an out-of-network cardiologist?
His PCP refers out by habit — two in-network cardiologists had openings that week.
- 02/10pcp visit · chest pain · referral written
- 02/11referral to out-of-network cardiology
- 02/11in-network · 2 cardiologists · open slots
- 2025same pcp · 41 cardiology referrals · 33 out
Send Each Finding to Whoever Acts On It
Scorecards change behavior when they reach the right desk. Ana sends each group its own scorecard, the referral patterns to provider relations, and the contract findings to the team renegotiating.
- Scorecards sent to each group on a schedule
- Referral patterns to provider relations
- Contract findings ready for renewal
What should the network team do this quarter?
Renegotiate one contract, steer one episode, and fix one referral pattern.
- contracting Group D knee episode at 2.3× peers
- care nav. Steer knee replacements to groups A and B
- provider rel. 12 PCPs referring cardiology out of network
- groups Monthly scorecards for 31 groups
Score Your Network
Bring a year of claims and your provider contracts. We join them inside your cloud and hand your network team the episodes, groups and referral patterns worth acting on.
- 01A 30-minute call to pick the episodes and the markets in scope
- 02We connect inside your cloud under a BAA — nothing leaves your environment
- 03Your network team works the findings with us
Where Network Work Starts
- 01 Provider scorecards
Cost, quality and access for every group against its contract and its peers, sent on a schedule.
- 02 Episode cost variation
The same episode compared across every group, with outcomes beside cost.
- 03 Referral leakage
Out-of-network episodes traced to the referring provider and the reason.
- 04 Shared-savings performance
Attributed spend against each value-based contract’s target, as claims arrive.
- 05 Network adequacy and access
Wait times and capacity by specialty and region, before a regulator asks.
- 06 Contract renewal prep
Each group’s performance and rate position, ready for the negotiation.
With your team’s definitions, versioned in the ontology — the trigger claim, the window and what counts in it — so every group is compared on the same episode.