CASE STUDY
Benefis + Ensemble secure material wins with payers in first 90 days.
Payer strategy support helps secure precedent-setting contract terms, improve annual net revenue by more than $567k and accelerate claims resolution.
SNAPSHOT
Benefis came to Ensemble with a clear mandate: Stabilize payer performance quickly, unlock stalled negotiations and reduce administrative friction that was driving denials and cash delays. Within 90 days, collaborative efforts by Ensemble’s payer strategy support strengthened Medicare Advantage (MA) contract terms, including raising the letter of agreement (LOA) basis to 105% of CMS. We also increased payer transparency by establishing semiannual claims reviews, improved annual net revenue by more than $567k through contract renewal and furthered claim recovery with demand letters covering $1.6M+ and Epic protections totaling $1.25M.
PROFILE
- Health system
- $708M NPR
- 3 hospitals
- Mountain West
- End-to-end RCM partner since September 2025
Background
From day one, Benefis leadership created the conditions for speed, empowering Ensemble’s team to lead on several critical fronts and making time for weekly problem-solving sessions. That combination of executive sponsorship and clear decision authority let us compress a typical multi-quarter timeline into weeks.
We organized the work around one simple principle: protect what works, fix what doesn’t and codify accountability so improvements stick. That meant moving on two tracks at once by locking in contractual clarity where ambiguity was causing waste, and escalating claims recoveries with the right documentation, cadence and escalation paths.
Securing precedent-setting Medicare Advantage contract terms
A key early priority was strengthening Medicare Advantage terms, where ambiguity around CMS policy frequently drives preventable denials. Benefis empowered Ensemble to lead negotiations with a particular payer — a decision that proved pivotal.
Our experts reframed the negotiation around explicit CMS alignment instead of informal interpretation. The resulting MA agreement:
- Includes clear, written adherence to the CMS Two-Midnight Rule and sequestration policy, reducing retroactive disputes and protecting Benefis clinicians from second‑guessing long after care is delivered.
- Formalizes twice‑yearly side‑by‑side claims reviews with named payer SMEs to ensure administrative issues are surfaced and resolved on a predictable cadence. The inclusion of payer adjudicators with authority to resolve claims in real time is what makes these sessions successful, turning them from reactive firefighting into structured payer accountability and measurable cash recovery events.
- Secures meaningful administrative and financial protections that reduce avoidable write-offs and strengthen cash realization, including timely filing extended from 180 days to 365 days and an increase of the LOA basis from 100% to 105% of CMS, directly raising the floor on out-of-network payments and mitigating downside exposure while negotiations or disputes are resolved. Together, these provisions materially reduce administrative risk while improving both predictability and net yield.
These provisions set a precedent. Benefis now has a template for future MA negotiations, grounded in compliance, transparency and enforceable operating rules.
Results
First payer at Benefis to codify the CMS Two-Midnight Rule in contract language
Semi-annual claims reviews codified
Inpatient/outpatient percentage‑based reimbursement preserved
Re‑accelerating a stalled commercial renewal
While MA terms were being strengthened, Benefis also needed to resolve a stalled negotiation which had been in flight without movement for several months.
Ensemble rebuilt the financial case using regional market benchmarks and internal cost modeling to create a defensible counterproposal. We structured conversations to remain collaborative, escalating only as needed when decisions stalled.
That approach set things in motion. The payer accepted the majority of the counter‑proposed terms, and the agreement was signed December 22, 2025, effective January 1, 2026, 90 days after Benefis’ contract began with Ensemble.
Critically, Benefis preserved inpatient/outpatient percentage‑based reimbursement — a core methodology that protects access, predictability and long‑term financial stability.
This renewal shows that negotiations centered on transparent math and clear operational rationale can strengthen both financial outcomes and payer relationships.
Rapid claim resolution
Contracting progress had to be matched by near-term cash actions. Ensemble launched a disciplined claims resolution program with formal demand letters where documentation and timeliness were at risk.
For one major payer, we addressed a $1.6M impacted inventory and secured active engagement from the provider representative. For another, we moved quickly on out-of‑network issues. To mitigate the predictable noise from a major EHR transition, we also issued more than $1M in Epic transition Good Faith letters to preempt denials and create a paper trail for disputed payments.
Why this worked
These positive results come down to an effective operating model, not heroics. Executive sponsorship granted clear deal authority and a predictable cadence to resolve blockers. Contracting prioritized CMS policy alignment and operational transparency, instead of just headline rate wins. Negotiations were anchored in defensible math from regional benchmarks and cost models.
Claims actions followed an escalation ladder, moving from the payer rep to a supervisor to a regional lead to a national lead, with regulatory/legal paths when warranted. This was supported by complete documentation packets and consistent follow through.
Every change connected back to the front line with updated job aids and edit logic so improvements showed up in day-to-day processes.
For hospital leaders looking to meaningfully improve payer performance, here are the elements required to compress a typical multi-quarter cycle:
- Clear executive authority: Ensemble was empowered to lead negotiations.
- Weekly unblock cadence: Collaborative problem-solving prevented issues from aging.
- Contracting based on operational reality: Negotiations focus on CMS alignment and claims transparency.
- Data‑driven proposals: Efforts were grounded in benchmarks and cost models.
- Structured escalation: Demand letters, documentation packets and regulatory paths were intentionally deployed when needed.
- Front‑line integration: Job aids and edit updates aligned to contract changes.
Results
(from 180 to 365 days)