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Healthcare > Health Payor Practice

Health Payor Practice

Umbrex connects health payors to independent consultants with deep experience in the industry.

Over 90% of our Health Payor Practice consultants are alums of McKinsey, Bain, or BCG.

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Client Segments Umbrex Serves

  • National Multi-line Health Insurers: Large diversified carriers across commercial, Medicare, Medicaid, operating nationally with complex portfolios, scale networks, and enterprise functions.
  • Regional & Provider-Sponsored Health Plans: Independent Blues, community non-profits, and IDN-owned plans competing regionally across select lines, balancing growth with local network and regulatory dynamics.
  • Government-Program Specialists: Medicaid MCOs, Duals, and MA-focused plans primarily serving government programs, competing in procurements, bids, and compliance-intensive markets.
  • Pharmacy Benefit and Specialty Managers (PBMs): Organizations administering pharmacy and specialty benefits, formulary and rebate management, specialty networks, and medical-pharmacy programs for plans and employers.
  • TPAs, ASOs & Stop-Loss Carriers: Administrators and risk partners serving self-funded employers, providing claims platforms, care management, networks, and financial protection.”

Selected Capabilities of our Health Payor Practice

Strategy & Corporate Development

  • Enterprise Growth Strategy And Market Prioritization: Quantify demand and competitiveness across Medicare Advantage, Medicaid managed care, ACA Exchange, and Commercial; prioritize geographies, segments, and products to accelerate enrollment growth and margin.
  • Product Portfolio And Benefit Design Strategy: Design differentiated portfolios for Medicare Advantage, Duals, Exchange, and Employer; align benefits, supplemental offerings, networks, and pricing to improve acquisition, risk mix, and retention.
  • Government Programs Entry And RFP Win Strategy: Craft bid strategies for Medicaid procurements and Medicare Advantage expansions; shape value propositions, partnerships, and compliance narratives to increase awards and sustainable star ratings.
  • M&A And Corporate Development: Define acquisition theses across plans, TPAs, PBMs, and care delivery; perform commercial due diligence and synergy cases supporting integration roadmaps and shareholder value creation.
  • Vertical Integration And Ecosystem Strategy: Evaluate and structure plays in primary care, behavioral health, pharmacy, specialty benefits; design JVs and alliances to lower medical cost and improve experience.

Operations

  • Claims Operations And Auto-Adjudication Improvement: Redesign claim intake, edits, and adjudication; optimize benefit configuration and provider rules to raise first-pass yield, reduce rework, and meet prompt payment timeliness.
  • Enrollment And Premium Billing Optimization: Streamline enrollment reconciliation, retro changes, premium billing, and grace-period workflows to reduce enrollment errors, delinquency, and member abrasion across Commercial, Medicaid, and Medicare Advantage.
  • Provider Data Management And Directory Accuracy: Centralize provider data operations, credentialing feeds, and attestation; fix duplicates and effective dates to meet directory accuracy rules, reduce claim rejects, and improve network search.
  • Appeals, Grievances, And Complaint Operations: Redesign intake, categorization, routing, and resolution; implement turnaround time controls, quality reviews, and root-cause analytics to ensure CMS compliance and reduce repeat complaints.
  • Payment Integrity And Coordination Of Benefits Operations: Operationalize prepay and postpay edits, coordination of benefits, subrogation, and overpayment recovery to cut improper payments, reduce medical loss ratio, and protect provider satisfaction.

Procurement & Strategic Sourcing

  • Enterprise Spend Baseline And Category Strategy: Baseline indirect spend; craft category strategies for IT, BPO, print/mail, analytics, and facilities to cut total cost, tighten compliance.
  • Core Administration Platform Sourcing And Negotiation: Run RFPs for claims, care management, CRM, EDI platforms; negotiate SLAs and total cost to improve functionality, integration, savings.
  • PBM And Pharmacy Benefit Procurement: Structure and run PBM RFPs; negotiate guarantees, pass-through pricing, rebates, specialty channel terms, audit rights, and transparency to lower pharmacy trend and administrative fees.
  • BPO Selection And Outsourcing Governance: Source and negotiate business process outsourcing for claims, enrollment, and member services; define SLAs, quality, incentives, and regulatory controls to reduce cost and improve experience.
  • Vendor Risk Management And Contract Compliance: Build third-party risk management, HIPAA business associate agreements, SOC 2 reviews, and performance scorecards to manage cybersecurity, data privacy, and contract compliance across vendors.

Product

  • Product Portfolio Strategy And Roadmap: Define multi-line portfolios across Medicare Advantage, Medicaid, Exchange, and Commercial; segment members, differentiate value propositions, and sequence innovations to grow enrollment, margin, and retention.
  • Benefit Design And Plan Architecture: Design benefits and cost sharing aligned to essential health benefits and actuarial value (AV); optimize out-of-pocket maximums, copays, and tiering to improve affordability and competitiveness.
  • Medicare Advantage Supplemental Benefits Optimization: Optimize Medicare Advantage supplemental benefits—dental, vision, OTC, transportation, Special Supplemental Benefits for the Chronically Ill (SSBCI)—to boost Stars, acquisition, retention, while controlling costs and utilization.
  • Exchange Product And AV Optimization: Design Affordable Care Act Exchange products; calibrate actuarial value (AV), cost-sharing reduction (CSR) variants, and deductibles to maximize risk-adjusted margin and on-exchange enrollment growth.
  • Product Lifecycle Management And Filing Excellence: Establish governance; coordinate Health Plan Management System (HPMS) bids and System for Electronic Rate and Form Filing (SERFF) submissions to achieve approvals and launch readiness.

Organization

  • Enterprise Operating Model And Governance: Design health plan operating model across Commercial, Medicare Advantage, Medicaid, and Exchange; define decision rights, committees, and governance cadence for medical management, network, compliance.
  • Organizational Structure And Spans And Layers: Redesign regional and functional structures for claims, enrollment, provider operations, medical management; optimize spans and layers to speed decisions, reduce cost, clarify accountability.
  • Shared Services And Centers Of Excellence Design: Stand up shared services and centers of excellence for provider data, Stars and HEDIS, risk adjustment, analytics, credentialing; define service catalog, SLAs, cost allocation.
  • Talent Strategy And Workforce Planning: Build workforce plans for nurses, medical directors, coders, actuaries, data scientists, and member services; define location strategy, career paths, and upskilling to meet growth, compliance.
  • Performance Management And Incentive Design: Align KPIs and incentives to Stars, HEDIS, risk adjustment yield, medical cost management, auto-adjudication, call center service levels, and compliance; implement scorecards and governance.

Marketing

  • Brand Positioning And Messaging Architecture: Create differentiated brand and messaging by line of business; align value propositions to seniors, Medicaid, Exchange, employers to improve awareness, consideration, and trust.
  • Consumer Acquisition For Medicare Advantage And Exchange: Orchestrate Annual Enrollment Period and Open Enrollment Period campaigns, creative, media mix, funnels, and call center scripting to lower acquisition cost and increase qualified enrollments.
  • Broker And Employer Marketing Enablement: Develop co-branded materials, proposal content, decision-support tools, and thought leadership; activate broker portals and campaigns to grow group leads, proposal shortlists, and win rate.
  • Digital Performance Marketing And Attribution: Optimize paid search, social, display, and web; implement privacy-safe tracking and multi-touch attribution to improve conversion rate, lead cost, customer acquisition cost, and enrollment yield.
  • Member Retention And Experience Communications: Design onboarding, benefits education, and proactive communications; segment by risk and language to raise retention, satisfaction scores, and digital self-service adoption.

Sales

  • Sales Channel Strategy And Coverage Model: Define mix of broker, general agency, direct, telesales, and field; design territories and staffing by segment to increase qualified leads, conversion, and enrollment.
  • Broker And General Agency Enablement: Segment brokers and general agencies; define contracting, commission schedules, bonuses, tools, and portals; deliver enablement to grow quotes, finalist rates, and bound groups.
  • Employer Group Sales Pursuit And RFP Excellence: Build win playbooks for administrative services only and fully insured; orchestrate underwriting, pricing, clinical programs, and finalist presentations to lift win rate and margin.
  • Medicare Advantage Agent Strategy And Compliance Readiness: Optimize agent recruiting, licensing, appointments, compliant training, scripts, and quality monitoring to increase Medicare Advantage enrollment conversion while meeting sales and marketing regulations.
  • Sales Compensation, Quotas, And Pipeline Management: Design compliant compensation plans, quotas, and incentives; configure CRM (customer relationship management) stages and forecasting to improve productivity, forecast accuracy, and enrollment yield.

Finance

  • FP&A And Driver-Based Budgeting: Build driver-based forecasts from membership, premium per member per month, medical loss ratio, Stars revenue, and admin costs to improve budget accuracy, guidance, and agility.
  • Product And Market Profitability And Cost Allocation: Build PMPM profitability by line of business, market, segment; allocate shared services and care management to inform pricing, portfolio decisions, and exit or expansion.
  • Administrative Expense Optimization And Benchmarking: Benchmark selling, general, and administrative (SG&A) costs; redesign cost centers and allocations; implement zero-based budgeting to reduce admin ratio while safeguarding compliance and service.
  • Statutory Reporting, Close Acceleration, And Controls: Standardize National Association of Insurance Commissioners (NAIC) statutory reporting and reconciliations; accelerate monthly close and Sarbanes-Oxley (SOX) controls to improve accuracy, timeliness, and audit readiness.
  • Capital Planning, RBC, And Rating Agency Strategy: Optimize capital plan, surplus, and dividends; model risk-based capital (RBC), reinsurance, and surplus notes; craft rating narratives to hit target ratings and cost of capital.

AI, Data & Analytics

  • Enterprise Data Platform And Governance: Build a cloud data lakehouse, master data management, and governance integrating claims, enrollment, clinical, and pharmacy to enable KPIs, analytics, and AI use cases.
  • Risk Adjustment Analytics And Suspect Identification: Identify Hierarchical Condition Category (HCC) suspects using natural language processing on charts and claims; prioritize outreach and validation to increase risk capture, RAF accuracy, compliance.
  • Stars And HEDIS Performance Analytics: Forecast measure performance; identify gaps and next-best actions to improve Medicare Advantage Star Ratings, HEDIS closure rates, CAHPS experience scores, and quality bonus revenue.
  • Predictive Care Management And Next-Best-Action: Predict avoidable admissions and emergency department use; prescribe outreach, benefits, and programs to reduce total cost of care and increase member engagement and retention.
  • Fraud Waste And Abuse Anomaly Detection: Use machine learning and network analytics to detect aberrant billing, upcoding, and phantom providers; prioritize investigations to reduce improper payments and medical loss ratio.

Transformation

  • Enterprise Transformation Office: Stand up transformation office with benefits tracking and finance lock to deliver admin ratio reduction, auto-adjudication lift, Stars gains, and medical loss ratio (MLR) impact.
  • Admin Cost Takeout And Operating Model Simplification: Execute cross-functional cost transformation—process redesign, automation, spans and layers simplification, vendor renegotiation—to lower administrative expense (SG&A), admin ratio, while protecting compliance and experience.
  • Digital Core Modernization And Platform Replacement: Orchestrate business-led modernization of admin, care management, and customer relationship management (CRM) platforms; sequence migrations and controls to de-risk cutovers and unlock cost benefits.
  • Post-Merger Integration And Synergy Realization: Plan and execute integration across products, networks, platforms, and vendors; capture general and administrative synergies; harmonize policies with Day 1–100 plans and value tracking.
  • Agile At Scale And Product Operating Model: Implement agile-at-scale and product operating model across benefits, digital, data, and operations; re-prioritize backlogs to speed regulatory releases, Stars fixes, and digital journeys.

Innovation

  • Innovation Thesis And Portfolio Governance: Set innovation theses, horizons, funding model, and stage gates; prioritize growth and medical loss ratio impact; establish metrics, pipelines, and governance cadence.
  • Venture Studio And New Business Incubation: Incubate and launch payer-adjacent ventures—virtual care, home-based services, navigation—through minimum viable products (MVPs), rapid tests, and commercialization to drive enrollment growth and cost-of-care reduction.
  • Startup Scouting And Ecosystem Partnerships: Scan digital health, remote monitoring, behavioral, pharmacy tech; diligence outcomes and unit economics; structure pilots, data sharing, and contracts to scale proven partners.
  • Payment And Care Model Experimentation Lab: Design and test value-based payment models, bundles, episode payments, and capitation; measure quality and total cost; scale models that improve affordability and experience.
  • Member Experience Innovation And Journey Prototyping: Run design sprints and service blueprints; prototype omnichannel journeys; test to lift Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores, retention, and digital self-service.

Compliance

  • Enterprise Compliance Program And Risk Assessment: Design enterprise compliance program with three lines of defense, annual risk assessment, policies, training, hotline, monitoring, auditing, corrective actions to prevent sanctions and fines.
  • CMS Program Audit Readiness And CAP Execution: Prepare for CMS Program Audits with accurate universes, mock audits, data integrity testing, and corrective action management to reduce audit findings, sanctions, and monetary penalties.
  • Medicaid Readiness Reviews And Contract Compliance: Prepare for Medicaid readiness reviews and surveys; implement controls for prompt pay, grievance timeliness, encounter data, and network reporting to avoid liquidated damages and sanctions.
  • Delegation And PBM Oversight Governance: Build delegation inventory, assessments, audits, and scorecards for utilization management, care management, claims, and pharmacy benefits; enforce corrective actions to ensure compliance and service quality.
  • Marketing, Sales, And Agent Compliance For Medicare Advantage: Operationalize Medicare marketing rules and TPMO oversight; implement call recording, disclaimer scripting, file review, and monitoring to reduce complaints, Rapid Disenrollments, and CMS sanctions.

Program & Portfolio Management

  • Enterprise Portfolio Governance And Prioritization: Stand up enterprise PMO and stage-gate governance; prioritize across Stars, risk adjustment, platform upgrades, and regulatory mandates to align capital and maximize portfolio value.
  • Benefits Realization And Value Tracking: Finance-lock business cases; track admin ratio, medical loss ratio, Stars, auto-adjudication, call center SLAs; dashboards, baselines, and owners ensure measurable value capture.
  • Regulatory Release And Filing Program Management: Manage CMS and state rules, rate and form filings, Notice of Benefit and Payment Parameters (NBPP), interoperability, and No Surprises Act timelines for compliant launches.
  • Capacity And Release Planning: Model business and IT capacity; sequence releases around Annual Enrollment Period (AEP), Open Enrollment Period (OEP), CMS freezes, Medicaid redeterminations to minimize disruption and risk.
  • Multi-Program Delivery And Dependency Management: Run integrated plans across core admin, data, care management, and provider systems; manage dependencies, cutover, and change control to de-risk go-lives and accelerate adoption.

Information Technology

  • Core Administration Platform Modernization And Integration: Select, implement, and integrate core claims, enrollment, billing, care management, and CRM platforms; rationalize interfaces and EDI to improve auto-adjudication, data quality, and uptime.
  • Interoperability And API Enablement: Implement HL7 FHIR Patient Access, Payer-to-Payer, and Prior Authorization APIs; modernize X12 gateways to meet CMS mandates, reduce friction, and accelerate provider transactions.
  • Cloud Strategy And Infrastructure Modernization: Define cloud adoption roadmap, migrate workloads, standardize networking and observability, and implement disaster recovery with defined RTO and RPO to improve resilience and cost.
  • Contact Center Technology Transformation: Deploy Contact Center as a Service, omnichannel routing, virtual agents, and CRM integration; absorb Annual Enrollment Period surges, cut handle time, increase first call resolution.
  • Cybersecurity And Identity Modernization: Design zero trust, multifactor authentication, privileged access, data loss prevention, and incident response; meet HIPAA and HITRUST objectives and harden defenses against ransomware.

Provider Contracting & Network Strategy

  • Network Adequacy Design And Geoaccess Modeling: Model time-distance, wait times, and panel capacity to meet CMS and state adequacy for Medicare Advantage, Medicaid, Exchange; optimize coverage while controlling unit cost growth.
  • Contracting Strategy And Rate Negotiation Analytics: Build negotiation targets by service line and site-of-service; model medical loss ratio impacts; secure escalators and terms improving competitiveness while containing unit cost trend.
  • Value-Based Contracting And Incentive Model Design: Design primary care capitation, shared savings, and episode bundles; define attribution, quality measures, and risk corridors to lower total cost of care and improve outcomes.
  • Network Performance And Leakage Management: Measure provider cost and quality; deploy tiered and narrow networks, steerage, and centers of excellence to reduce leakage, out-of-network spend, and unwarranted variation.
  • Out Of Network Strategy And No Surprises Act Playbook: Establish pricing policies, negotiation workflows, independent dispute resolution criteria, and wrap networks to lower out-of-network costs, arbitration exposure, and member abrasion.

Actuarial & Underwriting

  • Pricing And Rating Model Modernization: Modernize actuarial rating models across Commercial, Medicare Advantage, Medicaid; integrate trend, risk, network impacts to improve quote accuracy, win rate, and PMPM margin.
  • Group Underwriting Governance And Deal Desk: Standardize underwriting guidelines, risk tiers, authorities, and deal-desk processes for fully insured and administrative services only (ASO); speed quote cycles, improve conversion, and protect profitability.
  • ACA Risk Adjustment Strategy And Transfer Forecasting: Forecast ACA risk adjustment transfers by market and metal tier; calibrate pricing and product mix to minimize volatility, avoid surprises, and stabilize margins.
  • Reserving And IBNR Methodology Uplift: Enhance incurred but not reported (IBNR) reserving with improved completion factors, seasonality, and lag triangles; accelerate close and increase statutory reserve accuracy.
  • Reinsurance And Stop-Loss Optimization: Design specific and aggregate stop-loss, pooling, and ceded reinsurance; set attachment points and premiums to reduce volatility, protect capital, and sharpen competitive pricing.

Medical Management

  • Utilization Management Strategy And Prior Authorization Modernization: Redesign UM policies, clinical criteria, gold carding, and peer-to-peer workflows; cut avoidable utilization, provider abrasion, and improve turnaround time compliance.
  • Care Management Operating Model And Program Design: Segment populations; design case, disease, maternity, oncology, and transitions-of-care programs; align staffing and pathways to lower admissions, readmissions, and total cost.
  • Post-Acute And Site Of Care Optimization: Build steerage programs for SNF, IRF, LTACH, home health, outpatient infusion; implement clinical pathways to reduce length of stay, inappropriate settings, and PMPM spend.
  • Specialty Pharmacy Utilization Management: Design prior authorization, site-of-care redirection, split-fill, dose optimization, and adherence support; coordinate medical versus pharmacy benefit to reduce specialty trend and waste.
  • Behavioral Health Integration And SUD Programs: Integrate behavioral health with medical management; design collaborative care, tele-behavioral, and substance use disorder pathways to decrease high-cost utilization and improve outcomes.

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Find a consultant in our Health Payor Practice

Prefer email? Write to [email protected]

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