How One Payer Reprioritized Market-Based Pricing to Drive Savings
A Case Study in Reimbursement Strategy
A regional healthcare payer took a cautious approach to market-based out-of-network pricing. Over time, that changed. What started as limited use of Zelis’ Established Reimbursement Solution® (ERS) became a broader strategy that prioritized ERS for more claims.
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Executive Summary
At first, they were reluctant to rely more heavily on market-based pricing recommendations as part of their out-of-network reimbursement strategy. Like many payers, they had concerns about provider abrasion and dispute rates.
So instead of making a major change all at once, they took a gradual approach. The payer added Zelis’ Established Reimbursement Solution® (ERS) pricing recommendations to its ClaimPass® workflow over time. Later, they moved to a model that prioritized ERS.
That measured shift led to substantial savings growth while keeping dispute levels low.
Highlights
- ERS claim volume increased by 105%
- ERS savings grew from $11.5M to $21.4M
- The savings rate stayed at ~76%
- Provider dispute turnover remained under 4%
- Better positioning for stronger out-of-network savings in 2026
The Challenge
Balancing Claims Savings and Provider Stability
Like many payers, they were trying to balance several priorities at once. They wanted to protect member satisfaction, maintain provider relationships and avoid disrupting day-to-day operations.
At the same time, they wanted stronger out-of-network claims savings.
Before expanding ERS, the payer needed proof that they could improve results without increasing provider disputes or creating more friction in the process.
Goals:
- Maintain member satisfaction
- Protect provider relationships
- Avoid operational disruption
- Build confidence in market-based pricing
The Solution
A Gradual, Tailored Approach
The payer did not make this shift overnight. They moved forward in phases.
Phase 1: White Space Deployment
The payer launched ERS for a select group of claims, starting with a conservative scope.
Phase 2: ClaimPass® Integration
After observing stable provider acceptance rates and monitoring performance, the payer expanded ERS within its existing ClaimPass® workflow.
Phase 3: ERS-First Strategy
Once confidence grew, the payer shifted to a model that prioritized ERS as a preferred out-of-network savings channel, while keeping client-specific guardrails in place for certain claim types.
This phased approach helped reduce risk, build confidence and support broader adoption over time.
Results
More Claims Routed Through ERS.
More Savings Delivered.
The biggest change was not the savings rate itself. The real results came from routing more claims through ERS based on customized plan goals, member needs and provider attributes:
What changed:
- More claims were routed through ERS
- Savings grew
- Dispute levels stayed low
- Financial performance improved without destabilizing provider relationships
| Metric | 2024 | 2025 | Change |
|---|---|---|---|
| ERS Claims | ~13,000 | ~27,000 | +105% |
| ERS Savings | $11.5M | $21.4M | +86% |
| Savings Rate | ~76% | ~76% | Stable |
| Provider Dispute Turnover | <4% | <4% | Minimal impact |
Why It Matters
Many payers assume market-based pricing will lead to more provider disputes or higher overturn rates. This case shows that the outcome can look very different when the approach is thoughtful and tailored.
Impact when implemented strategically:
- Provider inquiry rates remain low
- Overturned savings are minimal
- Some disputes convert to negotiated savings
- Overall savings improve significantly
The Differentiator
Customization Made the Difference
This was not a one-size-fits-all model.
The organization was able to:
- Customize ClaimPass® routing workflow down to the employer group level
- Exclude specific provider types and claims
- Adjust ERS prioritization over time
- Expand gradually as confidence grew
Flexibility drove adoption.
Data built confidence.
Results supported expansion.
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