Network Leakage

The loss of patients and revenue when health plan members seek care from out-of-network providers instead of staying within the payer's contracted provider network.

Network leakage is a term payers use when their members go outside the network for care. From the payer's perspective, it costs them more because out-of-network claims are harder to manage and often more expensive. From your perspective as an in-network provider, leakage means patients who could be coming to you are going elsewhere. Leakage happens for several reasons. The most common is that the patient cannot find an in-network provider who has availability. If your wait time for a new patient appointment is six weeks, a patient who needs care sooner may go out-of-network. Another common reason is that the payer's provider directory is inaccurate, listing providers who are not actually accepting new patients. For credentialing, network leakage creates opportunities. Payers track leakage patterns closely. If they see that members in a particular zip code are consistently going out-of-network for cardiology, that tells them they have a cardiology gap in that area. They will actively recruit cardiologists to fill the gap, and you may get a more favorable contract as a result. If you are trying to join a closed panel, leakage data is your best argument. Ask the payer's provider relations team about leakage in your specialty and area. If you can demonstrate that their members are leaving the network for the services you provide, the payer has a financial incentive to add you to the network. Leakage also affects your existing practice. If a significant percentage of your patients have insurance with a payer you are not enrolled with, those patients are either paying out-of-pocket to see you or going to an in-network competitor. Running a payer mix analysis tells you which payers your patients have and whether there are enrollment gaps you should address. Some practices proactively ask new patients about their insurance during scheduling and use that data to identify payers they should credential with. If you are getting three calls a week from patients with a plan you are not in, that is a clear signal to start the enrollment process.