Payor Services

Empowering payors and health plans to improve quality, access, growth, and compliance.

Businessman and businesswoman working together on laptop

1 in 3

Health plan executives are prepared for upcoming regulatory requirements.^*

25%

Of health plan executives are considering investing in new partnerships or acquisitions.^**

95%

Of health plan executives are prioritizing provider accuracy and efficiency.^†

Helping health plans and payors overcome unique challenges.

With extensive industry experience, our healthcare consultants guide payors, risk-bearing organizations, and other stakeholders through regulatory and business challenges, helping them operate more effectively in achieving health for those they serve. We provide a wide range of consulting services for national and local payors, including managed Medicare and Medicaid health plans, public and private exchanges, state agencies, and commercial plans.

*“HealthEdge® Annual Payer Market Planning Report,” healthedge.com, 2025.
** “2024 HealthEdge Annual Payer Market Report,” healthedge.com, 2024.
^†"2023 Survey: Provider Data Accuracy & Efficiency a Top Priority for Health Plans,” healthcaredive.com, October 2, 2023.

Network Development & Strategy

In a competitive market where economic and political forces shape the way healthcare services are provided and accessed, today’s organizations must align their business models with future objectives and values. We can assist you with:

Network Development & Contracting: We provide services to support network expansion into new markets for commercial and governmental payors, special needs plans, narrow networks, and specialty networks, including behavioral health. We offer strategic support for Accountable Care Organizations (ACOs), independent physician associations (IPAs), and management services organizations (MSOs); integrated delivery system (IDS) development; health plan licensure (including Knox-Keene licensing); and risk-based contracting.
Growth: Our team has extensive experience supporting aligned growth for health plans. Our services include strategic planning, network and financial analysis, and market assessments for new lines of business and market expansions.
Data-Driven Tools & Insights: We provide a wide range of services to help analyze payor contracts and develop and implement effective provider contracting strategies. Our experience extends to claims, fee schedule, and capitation analysis; financial forecasting; provider data management; credentialing accreditation and support; and cloud-based customer relationship management (CRM) solutions.

Compliance

In an era of unprecedented change, healthcare organizations need value-added insight from experienced professionals. We work closely with health plans, providers, and risk-bearing entities to help them create effective programs, enhance processes, reduce risks, and meet regulatory compliance. Our team can assist with:

Regulatory Audit & Accreditation Readiness: We help healthcare organizations review operations, identify compliance issues, and implement solutions to prioritize readiness for regulatory audits and accreditation.
Operational Compliance: We leverage our team’s multidisciplinary experience to support efficient processes and operational outcomes that meet compliance requirements, accreditation standards, and internal policies.
Licensing: We help organizations obtain and maintain the appropriate licenses, certifications, and accreditations, as well as stay current with changes in licensing laws.
Delegation & Vendor Oversight: We help organizations oversee third-party tasks to confirm compliance with regulatory, accreditation, and contractual standards while holding third parties accountable for their performance.
Privacy, Fraud, Waste, & Abuse: We help design privacy programs, create monitoring plans, and train staff to recognize and report fraud, waste, and abuse.

Clinical & Quality Outcomes

Equipped with advanced clinical degrees and certifications, our healthcare consultants help organizations:

Develop and sustain quality programs that improve health outcomes
Promote the treatment team’s well-being
Limit organizational risk
Monitor for member and patient experience
Reduce overall costs

Our services include:

Policy & Procedure Development: We help create well-documented policies and procedures to prioritize quality care and improve health outcomes for those you serve.
Resource Management: We provide mentorship and coaching to help improve resource management and support appropriate, quality healthcare services.
Interim Leadership Support: Our team has extensive clinical, quality, and leadership experience across a wide range of healthcare organizations. We provide interim support for organizations experiencing turnover or staffing challenges.
Justice-Involved Healthcare: Correctional facilities face unique challenges in delivering quality healthcare services to medically underserved and complex populations. We leverage our knowledge and experience in correctional healthcare requirements, clinical and regulatory audit, continual quality improvement, and data analysis to offer quality assurance, compliance, and transformation services.

Business Technology Enablement & Transformation

Our team provides business technology consulting services to help payor organizations accelerate digital transformation, increase efficiency, achieve cost savings, reduce errors, and improve experiences for employees and customers. Our service offerings include: