Contracting Strategy Proves Successful in 2025
In my role leading provider relations, I have many conversations with prospects, clients and brokers regarding our contracting strategy. Our strategy is unique in the industry and one you’ll only find with ClaimDOC. This is not a one-size-fits-all or factory approach you tend to see in the reference-based pricing space. Our thoughtful approach does require stakeholders to trust our process, which can be more uncomfortable than us committing to strategies that sound good in a sales presentation but leave savings on the table. Due to this dynamic, I’ve been asked to share insights into what this looks and feels like for clients, based on actual 2025 results.
I continue to be surprised by two things in this space:
- Clients looking to get away from the damage caused by contracts in a network arrangement often immediately desire contracts to be used by their plan.
- Other RBP entities and cost-containment solutions are more than happy to walk clients right back into bad contracts.
Our strategy starts with the basic assumption that access to healthcare services is the top priority, and access and contracts are not the same thing. While this may seem basic to some, the distinction in healthcare has become completely blurred, with many so-called experts in this space seeing them as one and the same. In fact, blurring these concepts has been at the heart of the network-based healthcare system going back to the 1980s or even further. And while my kids will tell you that I love lots of things about the ’80s — Bon Jovi, big hair and no social media to name just a few — success for ClaimDOC and its members requires looking beyond the “contract-equals-access” approach of that great decade.
The key is to know when a contract is needed versus when a contract is a solution in search of a problem. Proactively reaching out and educating the providers on the plan, and creating access without a contract is always our first step. The value proposition for providers is we make it very simple and they avoid many of the same processes that come with the networks (e.g., credentialing). This requires a lot of work on our part, but the effort is critical to be able to develop relationships with members, save the plan money and obtain a detailed understanding of local markets. If a contract is the right answer for the situation, the next step is to understand what type of contract makes sense.
Most people assume this is where we’d start a conversation about a global agreement that mirrors the agreements from the PPO networks. Not so. Although they have a lot of sizzle and are a great sales story, we don’t start out with that mindset. In fact, we frequently find that some providers actually prefer limited agreements for certain circumstances (e.g., single patient, single cases, certain courses of treatment, etc.) and, in these cases, we are happy to negotiate a targeted agreement to address the immediate issues and leave the other care to be provided at our standard pricing. This is where the integrity of ClaimDOC and our willingness to do the hard work really benefits our clients. Securing global agreements always lightens the workload of our staff but, if we’re not careful, it can be a very expensive solution for a limited problem.
While it is fair to call us “contract cautious,” our provider relations team was very active putting together deals in 2025. In fact, the total number of contracts we completed averaged just under five agreements every single workday. In the lion’s share of these cases, our relationship with the providers is very positive even though we negotiate aggressively, using our vast experience and the mountains of data now available.
So how did we do in 2025? The numbers tell an exciting story:
- ClaimDOC processed more than 263,000 healthcare claims, a 20% increase over 2024. Nearly all of this growth was in nonhospital claims, which means more and more of the care received by members and their families is outside the traditional hospital setting.
- Only 10% were priced using a contract, which was a slight decrease.
- ClaimDOC plans’ overall allowable reimbursement as a percentage of Medicare decreased by 2 percentage points from 2024. Consider this decline while Medicare’s inflation adjustment was 2.5% and healthcare inflation was 8%.
- The balance bill rate declined to the lowest it’s ever been and remained under 1% of total claims for 2025. While we don’t try to minimize the impact balance bills have on members, they are becoming less frequent among our growing list of clients.
Ultimately, the provider relations team’s success is really the result of the efforts of our entire ClaimDOC team, coupled with the right strategy. The work is hard and demanding, but the positive outcomes achieved in 2025 demonstrate its value. At the end of the day, we earn the trust of our clients, and the numbers do not lie.