Client Success Stories
At Prosper Beyond, our clients’ achievements tell the story. Each success story showcases how healthcare providers have transformed their practices, strengthened payer relationships, and unlocked new revenue potential.
Payer contracting case studies
From securing favorable payer contract terms to optimizing revenue cycle performance, our clients have leveraged our adaptable expertise to reach their goals and beyond. Discover how our real-world solutions and tailored strategies, designed to adapt to the rapidly changing industry, have empowered healthcare leaders to elevate their impact and drive sustainable growth. We’re proud to share these milestones as a testament to the transformative power of informed, strategic payer contracting.
Case #1: FQHC
Prosper Beyond revamped payer contracting for an FQHC, renegotiating outdated contracts and transitioning to FQHC-specific methodologies. By analyzing 24 contracts, increasing reimbursement rates, and securing multi-year agreements, Prosper Beyond delivered over $1.1 million in added commercial revenue, enhancing financial growth and payer relationships.
A Federally Qualified Health Center (FQHC) had not renegotiated its payer contracts in over 10 years. The group needed to migrate existing Medicare Advantage and Medicaid contracts to the FQHC methodology and request increases from payers for commercial products. Additionally, the group needed to address below-market rates for behavioral health contracts as well as dental network reimbursement.
The team analyzed a total of 24 contracts in detail, creating a comprehensive assessment that outlined the contract value to the organization and the administrative burden implications. We developed a roadmap for renegotiation strategy and created a succinct, impactful value proposition that highlighted key areas relevant to each payer. Meetings were conducted with payers to build relationships and work on increasing contract value in terms of rates while also reducing administrative burdens. The team strategically targeted all impactful payer contracts, successfully renegotiating rates and securing multiple-year agreements with the majority of payers. We also identified new value-based programs available to the group and terminated a few underperforming agreements when payers failed to meet reasonable market rates.
The estimated annual economic impact included over $1.1 million in increased commercial reimbursement rates. The team successfully migrated Medicare Advantage contracts to FQHC arrangements, negotiated favorable terms with commercial payers, increased filing limits, secured favorable amendment language, and more. We also identified new value-based arrangements and assisted in establishing communication pathways with payers to foster ongoing relationship-building and collaboration opportunities.
Case #2: Family Medicine
Prosper Beyond successfully transitioned a family medicine practice with 5 physicians and 11 mid-level providers from a clinically integrated network (CIN) to direct contracts with 11 payers. By renegotiating fee-for-service rates, securing multi-year agreements, and identifying new value-based opportunities, we delivered over $1.6 million in annual economic benefits while reducing CIN expenses and strengthening payer relationships.
A family medicine practice consisting of 5 physicians and 11 mid-level providers wanted to exit its contractual relationship with a clinically integrated network (CIN) and contract directly with the 11 payers currently involved through the CIN. The practice had been in this relationship for over 10 years and was frustrated by the lack of transparency regarding shared savings distribution. They identified a better value-based partner and needed to act quickly to secure direct agreements with favorable fee-for-service rates.
We conducted a detailed analysis of 14 contracts, creating a comprehensive assessment that outlined rates, value-based impacts, and the implications of administrative burdens. We collaborated with the practice to secure direct contracts while simultaneously renegotiating a few other agreements outside of the CIN. We facilitated in-person meetings with many payers, presenting the practice’s value proposition and highlighting key areas of relevance to each payer. We reached out to all strategically significant payers and successfully renegotiated rates, securing multiple-year agreements with the majority of them. Additionally, the group terminated an underperforming contract when the payer failed to meet reasonable market rates, and we assisted with a communication plan.
The annual economic impact is estimated to include increases of $428,571 in reimbursement rates annually from commercial, Medicare, and Medicaid sources, as well as over $1.2 million in value-based program funds. The practice also reduced its participation expenses in the CIN, which included a 15% withhold and additional quarterly dues. We successfully transitioned contracts from the CIN to direct arrangements. Furthermore, we negotiated favorable contract terms with payers, eliminated penalties, secured advantageous amendment language, and identified new value-based arrangements and additional products. We also assisted in developing improved communication pathways with payers to enhance relationship-building and collaboration opportunities.
Case #3: Gastroenterology
Prosper Beyond partnered with a gastroenterology practice of 23 clinicians and three endoscopy centers to renegotiate 12 contracts, including new Medicare Advantage plans and existing agreements. By streamlining workflows, addressing missed revenue opportunities, and reducing administrative burdens, we delivered an annual economic impact of $4.75 million while fostering stronger payer relationships and simplifying the contracting process.
A gastroenterology practice, comprised of 23 clinicians and operating three endoscopy centers, was seeking a new consulting firm to assist with negotiating major payer contracts for both the clinic and the endoscopy centers. The group expressed concern that their previous consulting firm had complicated matters unnecessarily and did not maintain amicable relationships with payers. Furthermore, they were uncertain about the structure of several contracts and worried that they were missing out on potential revenue streams.
We renegotiated a total of 12 professional and facility contracts, taking into account the implications of administrative burdens and various contracting options. Eight of these contracts were existing agreements, while four were new Medicare Advantage plans. Our team managed the contract negotiations and assisted with proposals and evaluation of payer offers, adopting a detailed approach that considered fee-for-service rates and value-based offerings. We reviewed the agreements, provided guidance on billing practices, and identified significant missed revenue opportunities. We collaborated with the practice and providers to implement new protocols. The practice encountered various administrative challenges with payer contracts, so we proactively screened potential new payers using targeted questions to determine if administrative burdens would be part of the contract. This allowed payers the opportunity to alleviate these burdens or for the practice to decline the contract if necessary.
The annual economic impact of our efforts was $3.6 million on existing commercial contracts, with $1.15 million resulting from updated billing workflows. We successfully negotiated Medicare Advantage contracts, achieving rate increases of 3% to 5% and reducing administrative burdens. Additionally, we secured favorable contract terms with payers, including advantageous amendment language and the addressed interest penalties for slow payments. We simplified the complex contracting process and communication, helping the practice grasp critical information and summarizing key points at every step. Our efforts also focused on rebuilding relationships with major payers to enhance collaboration opportunities.
Case #4: Dermatology
Prosper Beyond helped a dermatology practice with 11 physicians and 12 mid-level providers renegotiate six major contracts and secure six new agreements across Medicare and Medicaid product lines. By increasing reimbursement rates, reducing administrative burdens, and achieving above-market rates, we delivered an annual economic impact of $984,513 while strengthening payer relationships and establishing a proactive strategy for future negotiations.
A dermatology practice in an urban market, comprised of 11 physicians and 12 mid-level providers serving communities across 6 locations, had not renegotiated payer contracts in the last eight years. The group aimed to renegotiate major contracts and explore new payers within Medicare and Medicaid product lines.
We conducted a detailed analysis of 12 contracts (six existing and six new) to create a comprehensive assessment. This assessment outlined the contract value to the organization, and the implications of administrative burdens, and established a roadmap for evaluating new contracts and renegotiating existing ones. We developed a tailored value proposition highlighting key areas relevant to each payer and engaged with them to build relationships and increase contract value in terms of rates while reducing administrative burdens. We successfully approached payers, renegotiated rates, and secured multiple-year agreements with the majority of them. We also identified new value-based programs available for the group. Additionally, we issued a termination notice to one payer who was unwilling to adjust rates to market levels, and we created a termination plan to support the practice through each step of the process.
The estimated annual economic impact of the negotiations resulted in over $984,513 in increased reimbursement rates through the renegotiated contracts, with improvements from five existing arrangements. We negotiated more favorable terms with commercial payers, enhancing termination language and eliminating penalty clauses. A termination of one contract was rescinded after the payer agreed to market rates through a multiple-year contract. We also identified several new value-based arrangements, which the group initially declined due to administrative burdens but will reconsider if those burdens are alleviated. Overall, we achieved above-market rates for both Medicare and Medicaid products and assisted in developing a proactive strategy for future negotiations with payers to focus on relationship-building and collaboration opportunities.
Case #5: Multi-Specialty Group
Prosper Beyond partnered with a rural multispecialty practice of 50 providers across 15 locations to renegotiate 10 contracts, including key Ambulatory Surgery Center agreements. By securing rate increases, eliminating penalties, and fostering collaborative payer relationships, we delivered over $5.6 million in annual economic impact while establishing a proactive strategy for future negotiations.
A multi-specialty practice located in a rural community, comprised of 50 providers across 15 locations, had not renegotiated their payer contracts in the past five years. The group aimed to build on previous successful negotiations and wanted to work collaboratively with our firm on several contracts to leverage an integrated approach for upcoming renewals. Additionally, the group needed assistance with a few Ambulatory Surgery Center (ASC) contracts as well.
We conducted a detailed analysis of 10 contracts, creating a comprehensive assessment that outlined the contract value for the organization, the implications of administrative burdens, and a roadmap for the renegotiation strategy. We developed a concise and impactful value proposition that highlighted key areas relevant to each payer. Meetings were held with payers (a few in person) to foster relationships and increase contract value, focusing on improved rates and reduced administrative burdens. We strategically approached all impactful payer contracts, successfully renegotiating rates and securing multiple-year agreements with most payers, while also identifying new value-based programs available to the group.
The annual economic impact is estimated to exceed $5.6 million due to increased reimbursement rates resulting from the renegotiation of four major contracts, with three payers agreeing to rate increases. We negotiated favorable terms with commercial payers, eliminating penalty language and securing advantageous filing limits. Additionally, we identified new value-based arrangements, although the group declined these due to administrative burdens. We assisted with a difficult ASC contract negotiation and successfully improved groupers and added carve outs for key services. We assisted in developing a proactive strategy for future renegotiations with payers, emphasizing ongoing relationship-building and collaboration opportunities.
Additional success stories
Physical Medicine: 1 MD
We received a payer amendment from the practice stating that rates would be reduced by -30%. The group had 30 days to respond and we assisted the practice in quickly terminating the product to minimize the loss.
Dermatology Practice: 6 MD / 3 APP
We renegotiated four major payer contracts and one minor contract, resulting in estimated increases of $617,788 annually to the bottom line while improving contract language provisions, including addressing recoupment timelines.
Family Practice: 5 mD / 5 APP
Our team successfully renegotiated two major payer contracts, securing increases of $260,319 with escalators in subsequent years.
Gastroenterology Practice with Endoscopy Centers
We renegotiated three major payer contracts and secured increases totaling $3,208,164. Additionally, we evaluated a value-based agreement that proved to be administratively burdensome and decided not to proceed with it.
Behavioral Health Provider with over 200 clinicians in 5 states:
We assisted the leadership team in developing payer-focused contracting strategies and created a tailored toolkit as a framework. Throughout the process, we acted as a sounding board and successfully opened previously inaccessible doors with payers.
Endocrinology Practice 2 MD / 4 APP:
With our support, secured a meeting with the largest payer in the state through escalation, resulting in $56,216 in additional annual revenue from rate improvements.
Internal Medicine Practice – 6 MD / 3 APP:
We evaluated new Medicare Advantage agreements and secured better rates for midlevel clinicians. Our team also assisted the group in transitioning from IPA agreements to direct agreements, resulting in a 24% improvement over IPA rates and added value-based incentives.