Payer Network Expansion Analytics

About the Customer

A growing health plan with 60,000+ members.

Problem

Lacked provider cost, quality, volume, and network insights needed to evaluate new markets

Outcome

60,000+ members served by a high-performing network

A growing Health Plan with more than 60,000 members used CareJourney’s data and analytics to expand to new markets across the nation.

Challenge

The Health Plan wanted to offer beneficiary services in specific states and counties, but they didn’t know where to start or which physician groups to target for their partnership network. Although the plan had access to data sources that indicate which health systems, providers, and facilities are located in specific geographies, there was no way to understand the quality, cost, and volume of each of these market participants, and how they were interconnected. The health plan faced additional challenges such as:

1. Limited access to data sources that identify providers within physician groups

2. Limited market analytics and insights catered toward their network expansion use case

3. Lack of understanding into how participants were connected via patient referral patterns or hospital affiliation

4. No solution to identify the right market participants to achieve network adequacy

How we helped

Knowing relevant metrics, market relationships, and the overall geographic healthcare landscape informs not only partner selection, but creates a health plan that is catered to a health plan’s member population.

Using CareJourney’s platform, powered by claims-data from over 130 million longitudinal lives and analyzed to the provider, practice group, facility, and network levels, the Health Plan was able to easily identify and partner with high performing primary care and specialty physician groups in their target geographies to offer competitive Medicare Advantage plans.

The health plan also used CareJourney’s Market Assessment tool to pinpoint the best market participants using advanced algorithms such as the CareJourney Provider Performance Index and open-sourced performance measures such as CMS’ Facility Star Ratings. Insights on an additional 40 metrics+ that included readmissions rate and unnecessary imaging spend, sourced from CMS’ Chronic Condition Warehouse, Choosing Wisely, and more, helped the health plan attain efficient market entry and health plan success.

Impact

By embracing CareJourney’s analytic solutions, the Health Plan was able to:

Expand their network to new geographic locations and advance value-based care
Evaluate network performance across cost and quality metrics at provider and practice group level
Achieve high network integrity between providers, groups, and facilities

Lessons Learned

1. Geographic provider data alone doesn’t reveal quality.

Knowing which providers exist in a market says nothing about their cost, quality, or volume performance.

2. Referral and affiliation patterns matter for network design.

Understanding how providers, groups, and facilities are connected helps build networks with real integrity, not just adequate coverage.

3. Network adequacy is an ongoing evaluation, not a one-time decision.

The plan continued to assess network performance and adequacy over time, not just at launch. Standardized, transparent performance indices (like a provider performance index or CMS Star Ratings) give plans a defensible basis for partner selection.

4. Broad claims data is critical.

130M+ lives in this case enable market-entry decisions that a single plan’s own data footprint couldn’t support alone.

“We were able to successfully expand our network into new geographies and evaluate network performance and adequacy over time.”