From Strategy to $50M: Inside a Managed Care Launch

Welcome to the April 2026 edition of The Helm, Sunstone’s executive briefing for Healthcare and Insurance leaders navigating growth, transformation, and scale. Each month, our Operating Partners share real-world insights from complex engagements to help leadership teams see beyond the horizon and build the capabilities required to turn opportunity into sustained results.

Like the ancient Vikings who used the Sunstone to find their path, we are ready to help you plot your direction and chart a course to become Extraordinary.

Headwinds & Currents

Payers and providers struggle with balancing competing objectives and financial pressures. Grievances between the parties include:

Provider View of Payers:

Administrative hurdles for claims processing and care coordination

Reimbursement less than cost and persistent delays or denials

Increasing patient collection issues from declining benefits

Intrusion into the provider/patient relationship

Payer View of Providers:

Billing irregularities

Insufficient value and evidence-based care

Unnecessary procedures

Patient referrals to non-contracted providers

This month, we share a success story that addressed these issues and created a new paradigm between payers and providers.

SMA Client Voyage

The Client's Storm

A national subspecialty provider with growing patient volumes and over 650 care centers was facing reimbursement pressure from its commercial payers. The payer’s perception of the subspecialty was:

No value-based measurements

Little clinical differentiation between care regimens

Inconsistent coding

No formal quality management, including provider credentialing

Inefficient, manual administration with a complex array of independent providers and one-off contracts

This perception revealed itself in some disturbing trends for the provider:

Rapidly declining reimbursement

Reduced benefits, forcing large patient collections or care avoidance

“Commoditization” of the services

Limited acknowledgment of clinical differentiation between complex care regimens and OTC solutions

Reluctant approval of innovative but more expensive patient treatments

Viewing Through the Sunstone

Discussions were held with payors to understand their concerns. Building an infrastructure that addressed these issues via a new subsidiary, the Company created a groundbreaking partnership that delivered cost-effective, quality care for patients at a fair price for the provider. This transformation redefined an entire provider subspecialty. Key deliverables included:

Total quality management program, including independent clinical oversight, credentialing standards, outcome studies, care and service quality improvement initiatives, and clinical guidelines

National network of owned and contracted independent facilities

Standard national contract form with a single fee schedule for the payer, but allowing for regional variances for the provider

An electronic interface for all data exchanges and a payment clearing house that consolidated all claims into a single EDI feed

Standard coding and claims edits

Provider/patient advocacy with a national service center

Signals

Built the entire subsidiary within 12 months

National network of over 1,200 provider locations

$50M in billings operationalized within Year 1

Successfully contracted with 4 national payers

Transformation requires a fervent commitment to change, a clear vision with granular specifications and rigorous project management.

Compass Points

Treated the payer as partners in the solution

Spoke to the Company and the industry at large on the challenges being faced, the need for fundamental new thinking, and the opportunity to change the game

Identified advocates to serve as change agents both inside and outside the company

Utilized rigorous project management to govern complex construction:
› Coordinated eight (8) parallel operational readiness workstreams
› Defined requirements and led vendor selection and implementation across claims processing, intake, payments, and analytics platforms
› Established a repeatable and scalable framework for ongoing process governance
› Facilitated Design, Requirements Development, and Implementation Activities across six (6) different 3rd party vendors

Set Your Heading

Assess your relationships with suppliers and move from adversarial negotiations to opportunities for collaboration

Do not underestimate the challenge of managing change. Try starting sentences with “Yes, if” instead of “No, because”

Transformation requires a relentless commitment to the journey and constant communication across the broad coalition of stakeholders

Invest in a formal and industrial-strength project governance structure

Book a Complimentary Voyage Briefing

If our perspectives on growth, transformation, and value creation resonate with you, let’s schedule a brief introductory call. We’ll listen, learn, and explore how our paths might align—no obligations, just dialogue.

Are You Ready to Be Extraordinary... To Go Beyond...?