How to Get a Health Plan to Say "Yes"

rebecca5521
18 minutes ago
4 min read

By Barry Volin, MCRA CEO Read part one of this series: "Selling is Hard and Getting Harder"

Selling into a health plan is never simple. Even when your solution meets a real need, the internal decision process can be slow and complex. This piece looks inside the health plan’s decision-making structure—why it’s so difficult to get a “yes,” and what you can do to improve your odds.

Understanding the Health Plan Environment

Health Plans are very complex organizations with countless departmental dependencies, interdependencies and competing priorities. They operate in an ever-changing regulatory environment, are responsible for managing a large, oftentimes non-compliant group of members and are dependent upon a provider network to ensure that access to high quality care is available and utilized.

The financial model they operate under is based on a fixed per member per month premium that must be managed aggressively to ensure both administrative processes and care needs are met. Member care compliance and engagement are ongoing challenges impacting Star scores and member retention.

With this understanding, it becomes apparent that Health Plans do not have an excess of discretionary revenue and must be extremely judicious in how and with whom they make solution investments.

Building a Strong Business Justification

Once an outsourcing need and potential vendor are identified, the business owner will be required to submit a business justification for the proposed engagement. The justification will define the need and be reviewed with the finance department. For example, the justification will identify whether the new need is being driven by a regulatory requirement or is intended to generate new growth or revenue. Key Performance Indicators (KPI) are also required as part of the business justification and will be evaluated against other enterprise requests.

The business owner will also develop a Scope of Work (SOW) that outlines the activities, key deliverables, metrics and timelines for use with the procurement team as they begin to engage with potential outsourcing partners.

Navigating Procurement and Compliance

The procurement team serves as the “point person” and coordinate the pre-sale assessment activities and document collection. At most plans, the procurement team will work with the business owner to identify other vendors (usually a total of three) who can fulfill the need and coordinate additional proposals from these vendors. As part of the vetting process, the procurement team will work with the vendor(s) to ensure they:

Comply with all relevant federal and state regulations
Monitor their employees and ensure they are not on any preclusion list
Provide references from current/previous clients.

It is incumbent on the vendor to understand these document needs and be prepared to produce them on a timely manner to facilitate the review process.

Many times, the procurement team will negotiate the financial terms of the agreement, performance (improvement) expectations and implementation timeline. They will require the vendor provides any specifics around needed resources, data collection and reporting, and ROI. Additional considerations will also include how the vendor addresses data security, security certifications, and business continuity, especially in the event of a data breach. Does the vendor maintain insurance to cover damages resulting from a data breach and how is it assigned?

Proving Value and Managing Expectations

The business owner is responsible for the measurable value of the solution being proposed and they are typically the individual that advocates internally to the Executive Leadership. The vendor should be prepared to provide a clear understanding of the projected savings, the basis of the projections, the timing until savings are accrued and any performance guarantees being made.

The vendor should be able to provide reports that illustrate how the impacted performance and their corresponding metrics will be monitored Marketing hyperbole such as “decreased emergency room utilization” or “reduced care costs” and “enhance member engagement” are effective sound bites, but it is necessary to define how they are measured, what is the baseline performance standard, and the expected level of improvement. Equally as important are the actions taken if the proposed improvements are not realized, is the contract terminated, are there monetary penalties or is another corrective action considered.

Planning for Implementation and Support

Lastly, but certainly no less important, is the implementation and ongoing maintenance of the proposed solution. How resource intense is the implementation and what is the implementation timeline? How disruptive will implementation be, especially considering any required staff training? Once the solution is operating, what type of commitment is the vendor making to maintain its regulatory/reporting compliance? Further, in the event of a system problem, how quickly will the vendor respond to the Health Plan's need for support?

Understanding the complexities and internal dynamics of a health plan may not speed up the process—but it will help you navigate it with clarity and purpose. The vendors who succeed are those who not only deliver value but also respect the realities of how decisions are made.

Come prepared with measurable outcomes, solid ROI, and a commitment to partnership—not just a product. When you align your solution to the plan’s goals and make the path to “yes” unmistakably clear, you don’t just win the sale—you build lasting trust and opportunity for future collaboration.