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Network Disruption Modeling Engine

Know your exposure before the network changes

Provider Impact

Model cost if high-volume provider leaves network

Facility Closure

Forecast utilization shift when hospital/ASC closes

Cost Exposure

Quantify PMPM impact of network disruption scenarios

The $840K Network Surprise

Your local health system gives 90-day notice: key orthopedic group is leaving network. Or ASA announces facility closure. Or your TPA loses contract with regional hospital. Network disruptions happen constantly— hospital mergers, physician retirements, contract disputes. Most employers learn about impact AFTER the disruption when Q2 claims spike 18%. Our engine models exposure proactively so you can negotiate, prepare, or switch networks before renewal.

Real Case: Orthopedic Group Exit

Discovered At Renewal (Reactive)
  • • Ortho group represents 240 employees + dependents (8.5% of population)
  • • Historical: $680K annual spend at in-network rates
  • • Out-of-network: members pay 40% coinsurance, plan still pays 60%
  • • OON facility charges 280% of prior allowed amount
  • • Plan cost increases to $1.14M (68% jump)
  • • Unbudgeted cost increase: $460K discovered at Q3 financials
Modeled Proactively (120 Days Before Exit)
  • • Engine flagged provider as 12% of total medical spend
  • • Modeled 3 scenarios: stay with network, switch carriers, carve-out contract
  • • Negotiated direct contract with ortho group: 140% Medicare
  • • Alternative: switched to carrier with this group in-network
  • • Actual cost impact: $720K (direct contract) vs $680K baseline
  • • Avoided $420K surprise via proactive modeling + contract

Common Disruption Scenarios

High-Volume Provider Exit

Single provider or group represents 5-15% of your medical spend. When they leave network, members either pay OON cost-share (plan still liable for 60-70%) or disrupt to new in-network provider (unknown cost).

Risk Factors: Specialty groups (ortho, cardiology, GI), single-specialty ASCs, high-cost infusion centers

Hospital System Merger

Two systems merge, one was in-network, other wasn't. Post-merger they want single contract at higher rates. Or merged entity terminates contract to gain negotiating leverage.

Cost Impact: Typical demand: 12-20% rate increase or termination; affects ER, admissions, outpatient surgery

Facility Closure

Local ASC closes or hospital converts to urgent care only. Historical utilization redistributes to remaining facilities—often at higher cost if nearest alternative is more expensive.

Example: Low-cost ASC closes; procedures shift to hospital HOPD (facility fee 2.5x higher)

Geographic Network Gap

You have 80 employees in satellite office; nearest in-network hospital is 45 miles. Local hospital not contracted. Employees use local facility, all OON claims.

Solution: Model cost of status quo vs. direct contract with local facility vs. moving to broader network carrier