Inside the mind of a health plan— what they really care about when contracting for virtual care

Executive Summary

• Telehealth growth can’t depend on patient experience alone; true scale comes from building for health plans.

• Health plans scale telehealth when it delivers predictable utilization, measurable savings, and airtight compliance.
• The winners earn health plan trust with transparent data, nationwide reach, and seamless integration that make them essential partners.
• Bridge enables telehealth companies to operate at national scale with the clinical rigor and compliance infrastructure health plans demand.

Intro

You’re building a telehealth service that fundamentally makes healthcare better— it’s more accessible care, a better patient experience, and it costs all stakeholders far less. You’re experimenting with various business models and growth is hard. You might have gone direct to consumer, but you’ve found that most consumers think that if something feels like healthcare, it should be covered by their insurance. You’ve also pursued employers only to discover slow growth from a deep resistance to a growing arsenal of point solutions paid for on top of their health plan.

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For years, telehealth companies have designed their service to delight patients. If we make our service so insanely good, patients will flock to us, right? But with so much focus on the patient experience, we neglect the primary stakeholder— health plans. Health plans unlock the holy grail of telehealth— in-network, nationwide coverage.

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Patients, and your investors, are demanding that telehealth companies rethink your foundational priorities. Instead of obsessing over the patient experience, treat that as table stakes, and, from day one, obsess over the health plan experience. It’s pretty easy to understand what patients need— convenient access to affordable care all wrapped up in a service that makes them feel heard. But health plans are a bit of a black box to most of us. So let’s dive into the fascinating mind of a health plan and truly understand what they need to be a happy partner that unlocks your holy grail.

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A health plan’s job to be done: ensure utilization is appropriate and predictable.

Above everything else, health plans care about their costs and making them as predictable as possible. But it's not just about reducing utilization—it's about ensuring the right utilization. Health plans want not too much, not too little, but just the right amount of care that keeps members healthy while maintaining cost predictability.

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Anything new throws a wrench in their prediction engine. Health plans operate on fixed premiums collected upfront. They're essentially making a bet: that the premiums they collect will exceed the cost of care they'll need to provide. This means unexpected spikes in utilization can quickly erode margins or even push a plan into the red. When evaluating new telehealth services, they're asking "can we accurately forecast what this will cost us?" and "will this increase or decrease our total cost of care?" This explains why many plans initially resist telehealth expansion—not because they doubt its clinical value, but because they fear it will become additive utilization rather than substitutive care, making their cost predictions obsolete. For plans to embrace telehealth at scale, they need ironclad data showing cost neutrality or savings through appropriate utilization—care that happens at the right time, in the right setting, preventing more expensive interventions down the line.

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For example, according to a study published in Health Affairs, among Medicare Advantage enrollees, practices with high telehealth access saw a 13.4% decrease in in-person evaluation & management (E&M) visits. That reduction in in-person visits was largely offset by increased telehealth E&M visits, such that total E&M volume was approximately stable.

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Also, high telehealth access was associated with a 4.8% reduction in total ED visits.

This study suggests that the right access to care, at the right time, maximizes the right utilization for a population.

Health plans ❤️ data

For health plans, data is the foundation of their entire business model. Plans use data to set premiums, negotiate provider contracts, identify high-risk members, predict future costs, demonstrate value to employers, and comply with an ever-growing list of regulatory requirements. When a telehealth company can't provide clean, timely, comprehensive data, they become a black box that introduces uncertainty into the plan's forecasting models and reporting obligations. The smartest telehealth companies recognize this and design their services to be exceptional data partners from day one. This means going beyond basic claims data to share:

• Real-time utilization metrics (visits by specialty, time of day, state, and member demographics)
• Clinical outcomes data (diagnosis patterns, treatment adherence, care gaps closed, preventable ED visits avoided)
• Cost impact analysis (what care was substituted vs. added, downstream cost effects)
• Member satisfaction and engagement metrics
• Quality measures that map to HEDIS and Star Ratings.

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The smartest telehealth companies structure their data story in three phases, each building credibility for the next. Phase 1 proves members actually use and love the service—high engagement rates, NPS scores, and satisfaction metrics that show you're not a ghost network. Phase 2 demonstrates clinical impact—improved adherence, closed care gaps, better health outcomes that prove the care works. Phase 3 delivers the holy grail: member savings through reduced ED visits, avoided hospitalizations, and prevented complications. Each phase is a prerequisite for the next. Health plans won't care about your cost savings claims if members aren't engaged, and engagement without clinical outcomes is just expensive entertainment. Lead with proof of adoption, follow with proof of efficacy, close with proof of ROI—and make all of it transparent, real-time, and actionable.

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The gold standard is providing this data in formats that integrate seamlessly into the plan's existing analytics infrastructure—think flat files, API access, or direct data warehouse connections rather than static PDFs. Telehealth companies that proactively share granular, actionable data transform themselves from vendors into strategic partners. They help plans tell better stories to their employer clients, identify opportunities for care management interventions, and ultimately build the business case for expanding telehealth benefits. Being the most transparent, data-rich option is a powerful competitive advantage.

Satisfying employers and members

Health plans serve two masters: employers who pay the bills and demand affordable premiums with broad access to both traditional and innovative care, and members who need the plan to work seamlessly when they need it. Employers view robust telehealth as the baseline—a signal that their health plan is modern and comprehensive. Members want confidence they can access top-tier hospitals for serious issues, but also expect convenient care for everything else: a video visit at 8pm, a dermatology consult without taking time off work, mental health from their couch. The best health plans understand telehealth isn't either/or with traditional care—it's both/and. For telehealth companies, this means designing services that deliver clear ROI metrics to the plan while providing members an experience so smooth it builds trust in the health plan overall. When a telehealth service delights a member, the health plan gets the credit—and that goodwill translates directly into retention and satisfaction scores that drive the plan's competitive position.

Network adequacy— from everywhere to everything

Health plans are legally required to maintain adequate networks—meaning members can access the full spectrum of care, from routine check-ups to life-saving surgeries, within reasonable geographic distances. They track metrics like "time and distance standards" (how far members must drive to see a PCP or specialist) and "provider-to-member ratios" to satisfy state regulators and employer clients. This creates a paradox for telehealth: while virtual care theoretically eliminates geographic barriers, plans still need national consistency. A plan covering employees across all 50 states can't offer telehealth in only 5—that fragments the member experience and complicates communications. Plans want to message "you have access to virtual urgent care" without asterisks about state limitations. Equally important is integration with local care networks. When telehealth operates as a silo—disconnected from a member's PCP, local specialists, and medical history—plans worry about duplicated tests, conflicting treatment plans, and fragmented care that drives up costs while degrading outcomes. The ideal telehealth partner operates nationwide, maintains licensure and credentialing across all states, and integrates seamlessly into the existing care ecosystem through shared EHRs, warm handoffs to local specialists, and care coordination that closes the loop. Plans don't want to choose between geographic coverage and care integration—they need both to maintain true network adequacy in a hybrid care world.

Clinical quality and compliance: proving value, avoiding scandal

At the end of the day, health plans need to know two things with absolute certainty: the care is excellent, and it's legally bulletproof. Plans are increasingly measured on quality metrics—HEDIS scores, Star Ratings, and clinical outcomes—that directly impact their revenue and reputation. Poor-quality telehealth harms members and tanks the plan's performance benchmarks. But the compliance risk looms even larger. High-profile telehealth fraud cases—from questionable prescribing mills to kickback schemes—have made headlines and cost plans millions in fines, lawsuits, and reputational damage. Plans are terrified of being caught in a regulatory crossfire or associated with a provider that cuts corners. They need telehealth partners who are obsessively compliant: proper clinical oversight, documented medical necessity, audit-ready chart documentation, and adherence to prescribing guidelines and state-specific regulations. The best telehealth companies understand all of this and design their services accordingly. They build compliance into their DNA—robust clinical governance, regular audits, and quality metrics that map to what plans actually report. They don't ask health plans to trust them; they give plans every reason to view them as strategic partners who make the plan look good, perform better, and sleep easier at night. In a crowded telehealth market, this approach—being the lowest-risk, highest-value, most transparent option—is how you win and keep health plan contracts.

The non-negotiables for telehealth companies

Rule #1: The patient isn't your primary buyer—the health plan is. Great patient UX is now table stakes. Design for health plans. They’re the ones writing the checks. Every feature, every workflow, every data point should answer the question: "Does this make the health plan's life easier?"

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Rule #2: If you can't measure it, it didn't happen. Health plans live and die by data. If you're not proactively sharing real-time utilization, clinical outcomes, and cost impact in formats they can actually use, you're a black box they can't justify keeping. Be the most transparent vendor in their portfolio.

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Rule #3: Predictability beats innovation. Health plans don't want surprises—they want predictable costs. A "revolutionary" service that blows up their budget forecasts is a liability, not an asset. Show you're cost-neutral or cost-saving. Just as important: your innovative care model must fit within existing CPT codes and billing frameworks.

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Rule #4: Compliance is your competitive advantage. Be so buttoned-up, so audit-ready, so obsessively compliant that you're the partner they never worry about. Boring compliance is your moat.

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Rule #5: Go national or go home. A telehealth service that only works in 15 states is a fragmented liability. Health plans need consistency across their entire membership. If you can't operate in all 50 states, you're not solving their problem. This applies equally to self-insured employers—even mid-sized companies often have employees scattered across dozens of states, whether through remote work, regional offices, or distributed teams.

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Rule #6: Integration > disruption. Health plans don't want you to disrupt their network—they want you to enhance it. Connect to local PCPs, share data with specialists, close care loops. Siloed care duplicates costs and upsets everyone.

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Rule #7: Make the plan the hero. When your service delights a member, the health plan gets the credit with employers. When your data helps them hit Star Ratings, they get the bonuses. When your compliance is airtight, they sleep better. Design everything to make the health plan look good—because that's how you become indispensable.

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The mindset shift: You're not selling healthcare—you're selling peace of mind, predictable costs, and competitive advantage to health plan CFOs and network directors. Build for that, and your company will thrive.

The Bridge Benefit

Bridge is purpose-built to help telehealth companies deliver on every dimension health plans care about. With instant access to over 80% of commercially covered lives and 50-state coverage, Bridge solves the national consistency problem from day one. Our platform streamlines credentialing and enrollment in 30 days (versus 3-6 months with point solutions), uses standard CPT-based fee-for-service billing that fits seamlessly into health plans' existing actuarial models, and provides built-in clinical quality oversight and compliance infrastructure that makes telehealth companies audit-ready by default. In short, Bridge transforms telehealth companies from unpredictable vendors into transparent, compliant, data-rich participants in our healthcare ecosystem.

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