Client Profile
Type: National physician-owned and managed medical group
Services: Emergency Medicine, Hospitalist, Intensivist, and Post-Acute Coverage
Footprint: Multi-state and rapidly expanding
Challenge: Mixed in-network/out-of-network commercial payer contracting model without a centralized contracting function
The Challenge
As the organization expanded across the country, it operated under a patchwork of commercial payer arrangements—some markets were fully in-network while others remained out-of-network. The absence of a dedicated commercial contracting department made it difficult to:
• Launch concurrent payer negotiations across multiple states
• Establish in-network participation for newly opened locations
• Obtain competitive reimbursement rates aligned with the company’s acuity, staffing model, and quality of care
• Manage provider credentialing efficiently
The lack of a cohesive contracting strategy created reimbursement variability, administrative delays, and challenges in supporting continued national growth.
QHA’s Engagement
Quantum Health Advisors (QHA) was retained to lead the development and execution of a comprehensive Payer Strategy & Contracting framework that could scale with the organization’s expansion. QHA served as contracting strategist and negotiation lead across all service markets.
Our work focused on three areas:
1. Credentialing Streamlining
Credentialing delays were slowing the path to in-network agreements. QHA implemented a structured credentialing workflow to accelerate the process:
• Identified correct provider representatives for each commercial payer
• Ensured proper forms, submission protocols, and documentation requirements
• Verified processes before applications were filed
• Conducted standing weekly meetings to track status and resolve issues
Impact: Credentialing cycle times decreased—allowing in-network negotiations and facility onboarding to move forward without administrative bottlenecks.
2. Comprehensive Contract Review
To protect the organization’s long-term financial and operational interests, QHA reviewed all major payer agreements for:
• Timely filing requirements
• Reimbursement methodology and rate structures
• Amendment language enabling addition of new sites and clinicians
• Clauses that posed future financial or compliance risk
Impact: Agreements were structured for financial sustainability and future scalability across new markets.
3. Payer Representative Identification & Rate Negotiation
QHA directly led payer negotiations across multiple states. Our work included:
• Identifying the appropriate contracting and provider relations contacts
• Initiating and managing all negotiations
• Benchmarking competitive commercial reimbursement
• Securing favorable rate structures that reflect the services delivered
Impact: The organization achieved reimbursement levels that more accurately aligned with its cost structure and clinical value.
Key Outcomes
QHA delivered a set of tangible results including:
✓ In-network agreements secured across multiple states
✓ Formal relationships established with payer representatives
✓ Scalable contract templates
✓ Reimbursement rate premiums
✓ Internal readiness improved
Strategic Impact
The engagement allowed the company to transition from a reactive approach to a cohesive commercial payer strategy. With improved credentialing workflows, stronger contracts, and established payer relationships, the organization is positioned for more predictable reimbursement and sustainable national growth.
Quantum Health Advisors continues to support healthcare organizations across the country in developing contracting, reimbursement, and strategic commercial payer solutions that improve financial and operational outcomes.