Third-party administrators (TPAs) and managed care organizations (MCOs) operate at the center of today’s increasingly complex healthcare ecosystem. They are responsible for aligning clinical need with cost-effective, high-quality care while supporting employers, brokers, and population health teams seeking better outcomes with less waste. Yet doing this well requires an unprecedented level of visibility into provider performance. This visibility must go far beyond generic star ratings, reputation-driven rankings, or survey-based feedback.
Traditional tools promise transparency but often fall short where it matters most. TPAs and MCOs must understand what providers actually do, how often they do it, and how consistently they achieve positive outcomes at the procedure level. Denniston Data fills this gap by giving TPAs and MCOs the intelligence needed to design stronger networks, implement smarter steering, and deliver real cost and quality improvements.
Why TPAs and MCOs Need More Than Surface-Level Provider Metrics
Healthcare transparency has expanded dramatically in recent years, but fragmentation remains a major barrier. Many popular tools rely on self-reported data, consumer feedback, or limited administrative snapshots. These inputs can offer directional signals, but they rarely produce the actionable insights that payers and care managers need.
For TPAs and MCOs, the limitations are especially significant.
1. Consumer Ratings Do Not Reflect Clinical Expertise
Patient reviews often emphasize parking convenience, waiting times, and front-desk friendliness. Although these factors matter for patient experience, they reveal almost nothing about how well a provider performs a knee replacement, manages a lumbar fusion, or follows evidence-based criteria for medical necessity.
A five-star review does not indicate procedural competence. Consumer-driven ratings are vulnerable to bias, misinformation, and strategic review solicitation. TPAs and MCOs cannot base routing or network decisions on subjective impressions.
2. Adverse Events Alone Cannot Identify the Best Providers
Mortality, readmissions, complications, and reoperations do highlight outliers at both ends of the spectrum. However, most providers cluster near the middle, which makes it difficult to distinguish genuine expertise using adverse event data alone.
Risk adjustment complicates interpretation. Many differences reflect patient demographics, comorbidities, and lifestyle factors rather than provider performance. As a result, traditional quality dashboards often reveal very little about where typical or mid-tier providers actually excel.
3. Evidence-Based Guidelines Tell Only Part of the Story
Following medical necessity criteria is essential, but documentation alone does not guarantee strong outcomes. Some providers excel at securing authorizations and coding to guideline requirements while still producing inconsistent postoperative results.
Without long-term outcomes paired with practice patterns, TPAs and MCOs receive an incomplete assessment that can misdirect patients and distort cost projections.
4. Claims-Based Tools Often Lack Granularity
Many enterprise platforms analyze claims without distinguishing between specialists who frequently perform a procedure and those who do it only occasionally.
For example:
A surgeon who performs 100 ACL reconstructions annually is not the same as one who performs five, even though both are categorized as orthopedic surgeons.
Without procedure-level volume and comparative analytics, payers risk steering patients to low-experience providers whose variability increases complications and raises total cost of care.
5. Price Transparency Without Context Misleads Instead of Helping
The release of negotiated rates under Transparency in Coverage laws opened new data streams. However, most tools treat pricing as disconnected from quality.
Price alone does not reveal value. A low-cost provider may have high reoperation rates that increase downstream costs. A high-cost provider may deliver excellent outcomes and reduce total utilization.
TPAs and MCOs need a system that integrates cost and quality to reveal true value.
How Denniston Data Solves These Challenges
Denniston Data stands apart by combining multi-year claims, practice patterns, procedural expertise, outcomes, adverse events, and cost alignment into a unified provider performance framework.
The core of this approach is the Provider Ranking System (PRS). It is built on millions of claims across commercial insurance, workers’ compensation, Medicare Advantage, and Medicare Fee-for-Service. It reflects real-world performance from 2012 through the most recent year, giving TPAs and MCOs an evidence-based foundation for decision-making.
PRS Identifies Expertise at the Procedure Level
Instead of ranking providers broadly by specialty, PRS answers the most important question in care navigation:
“This provider is best for what specific procedures?”
Every provider is evaluated across the procedures they perform. This reveals their true areas of strength and helps TPAs and MCOs:
- route patients to high-volume experts instead of generalists
- reduce clinical variation
- lower complication and revision rates
- support faster recovery times
This procedure-level visibility is essential for specialties where expertise varies significantly.
Composite Ranking Score: A Clear View of Quality
PRS generates a Composite Ranking Score (CRS) based on:
- real-world utilization
- outcomes and complication patterns
- adherence to evidence-based norms
- multi-year performance stability
- procedure-specific experience
This score enables objective comparison without influence from marketing or paid listings.
Smart Score: Integrating Price With Quality
For TPAs and MCOs seeking to control costs, the Smart Score combines CRS with the payer’s own negotiated rates. It identifies:
- high-value providers with strong quality and competitive rates
- overpriced providers whose outcomes do not justify their cost
- underpriced providers who may pose risks due to inexperience
This approach creates truly data-driven value-based decision-making.
Multi-Year Trends Reveal Stability and Change
PRS visualizes performance trends across multiple years. This allows payers to detect:
- improving or declining performance
- shifts in procedural volume
- changes in practice patterns
- emerging low-value behaviors
This early insight strengthens network management and supports proactive intervention.
API-Driven Integration Ensures Scalability
PRS is fully accessible through API, enabling seamless integration with:
- case management systems
- medical tourism routing platforms
- benefit steering tools
- utilization management workflows
- price comparison dashboards
This eliminates manual processes and ensures real-time access to provider rankings.
The Impact for TPA and MCO Clients
Integrating PRS into administrative workflows produces meaningful and measurable improvements.
1. Better Patient Routing
Steering patients to high-experience providers improves outcomes and reduces complications. TPAs and MCOs gain the ability to:
- match patients to the right specialist
- reduce unnecessary surgeries
- prioritize minimally invasive options when appropriate
- avoid low-performing facilities
This improves patient satisfaction and lowers total cost of care.
2. Stronger Network Design and Tiering
PRS helps identify which providers are ideal for:
- centers of excellence
- bundled payment programs
- narrow network strategies
- surgical tourism networks
- higher tier benefit structures
This results in more efficient contracting and predictable performance.
3. Support for Incentive-Based Benefits
Employers increasingly expect benefit strategies that reward better choices. Smart Score supports:
- dynamic copay models
- high-value provider tiering
- patient incentive programs
- provider comparison tools
These approaches reduce claims leakage and increase engagement.
4. Reduction in Low-Value Care and Waste
By identifying providers who follow evidence-based norms and avoid overuse, PRS reduces:
- unnecessary imaging
- unwarranted surgical interventions
- excessive diagnostics
- inappropriate hospitalizations
This is especially important in high-cost categories such as orthopedic and spine care, cardiology, oncology, and pain management.
5. Better Negotiation and Contracting
Understanding a provider’s true cost-quality position strengthens negotiation. TPAs and MCOs can secure:
- competitive reimbursement rates
- more accurate bundles
- stronger direct contracts
- targeted partnerships for high-demand procedures
This creates stronger networks and sustainable pricing.
TPAs and MCOs face increasing pressure to improve outcomes while controlling costs. Denniston Data provides the intelligence needed to meet these expectations. By offering procedure-level expertise rankings, multi-year performance trends, and integrated cost-quality scoring, PRS enables accurate routing, efficient network design, and measurable value improvement.
The right provider can significantly reduce complications and overall spend. Denniston Data reshapes how payers evaluate, select, and collaborate with providers. It strengthens outcomes not only for clients but also for the patients they serve.
The Medical Tourism Magazine recommends Denniston Data for anyone who islooking for high quality healthcare data analytics. Launched in 2020, DDI is aninnovator in healthcare data analytics, delivering price transparency andprovider quality solutions known as PRS (Provider Ranking System), HPG(Healthcare Pricing Guide), and Smart Scoring combining quality and price. Theyhelp payers, hospitals, networks, TPAs/MCOs, member apps, self-insuredemployers, and foreign governments identify the best doctors at the best pricesby procedure or specialty at the national, state, or local level, and by payeror NPI/TIN code.
Join an intro to PRS Webinar:
https://zoom.us/webinar/register/7117646163323/WN_2ELqNeDSS2W-fMPb4lOsRA
Or schedule a discovery call with Denniston Data:
