What Toney HealthCare Consulting does

Toney Healthcare is a privately held, Tampa-based managed care consulting firm founded in 2008 by Dr. Sam Toney. The company provides clinical and operational advisory services to health plans nationwide, including utilization management, care management, physician review, quality advisory, special needs plan support, appeals and grievances, and population health programs. It serves Medicaid, Medicare Advantage, Special Needs Plans, TRICARE, and Commercial health plans across all 50 states and Puerto Rico with a US-based team of more than 350 clinical and operational specialists.

The firm operates three engagement models — Advisory Services, Insource Partnership (dedicated embedded teams), and Staff Augmentation — allowing clients to scope engagements from strategic guidance to fully outsourced clinical operations. Its core "technology" is its roster of credentialed clinical talent, including multi-state-licensed physician reviewers and senior nurse executives, supplemented by proprietary methodologies such as the Med-Psych Care Management approach. Following the February 2024 acquisition of Rebellis Group, the firm added Medicare Advantage-specific strategy, Stars ratings, and Part D consulting. The company is a portfolio company of Centre Partners and Health Enterprise Partners following their November 2022 joint investment.

Toney generates revenue on a professional services basis through enterprise contracts with health plans. Pricing is quote-based and not publicly disclosed, with engagement economics determined by scope, staffing level, and contract duration. Revenue figures are not publicly disclosed; the company is privately held and does not file public financials. Customers include at least 48 health plans, with named accounts including St. Vincent Catholic Medical Centers USFHP (TRICARE) and an unnamed large health plan covering more than 2 million members across Medicaid, Medicare, and Dual Eligible populations.

Name

Toney HealthCare Consulting

Legal name

Toney Healthcare Consulting

Website

https://toneyhealthcare.com

Company type

Private

Founded year

2008

Operating status

Operating

Headcount range

501–1,000 employees

Short description

Toney Healthcare is a Tampa-based managed care consulting firm that provides utilization management, care management, quality advisory, and clinical staffing services to Medicaid, Medicare Advantage, TRICARE, and commercial health plans across all 50 states with a 350+ person clinical team.

Ownership category

akta.pro rank

Headquarters

HQ city

Tampa

HQ country

United States

HQ region

North America

Offices1 record

Markets served

GTM type

B2B

Offering type

Services

Cost components

Personnel, Operations, Marketing or Sales, Technology or R&D

Revenue model

1. Clinical Operations Consulting: Provides expertise in medical and behavioral health management including operational execution, quality, accreditation and compliance. Services include utilization management, care management, physician review services, and quality advisory services.

Go-to-market motion1 record

Distribution channels2 records

Marketing channels4 records

Core offering

Toney Healthcare provides managed care clinical and consulting services to health plans, including utilization management, care management, quality advisory (Stars, QRS, HOS, URAC), physician review, specialty UM (SUD, ABA, MLTSS), population health, and appeals & grievances support. Services are delivered under three engagement models: Advisory Services (strategic consulting), Insource Partnership (dedicated clinical teams), and Staff Augmentation (flexible clinical/non-clinical staffing).

Product overview

Toney Healthcare is a clinically-oriented healthcare consultancy offering a comprehensive portfolio of managed care services to health plans nationwide. The company operates as a unified platform combining clinical operations expertise with strategic consulting capabilities. The core offering includes Utilization Management, Care Management, and Quality Advisory Services, supplemented by specialized services such as Physician Review Services, Specialty UM, Appeals & Grievances, and Population Health programs. Following the February 2024 acquisition of Rebellis Group (an expert model consulting firm focused on Medicare Advantage strategy, Stars ratings, and regulatory compliance), the company now also offers integrated Medicare Advantage consulting services including Part D expertise. Engagement models include Advisory Services, Insource Partnership (dedicated clinical teams), and Staff Augmentation. The company serves Medicaid, Medicare Advantage, Special Needs Plans, TRICARE, and Commercial health plans across all 50 states with a US-based team of over 350 healthcare experts.

Differentiator

Problem solved

Functional benefit

Products and services

• Utilization Management Medical and behavioral health utilization management services ensuring members receive the right care, in the right setting, at the right time; delivered to Medicare Advantage, Medicaid, TRICARE, and Commercial health plans.
• Care Management Medical, behavioral health, and integrated approaches to acute and complex case management, including Model of Care coordination for Special Needs Plan (SNP) populations.
• Quality Advisory Services Comprehensive quality improvement and regulatory compliance support including Stars ratings, QRS, HOS, URAC accreditation, and CMS regulatory compliance programs for health plans.
• Physician Review Services Expert multi-state-licensed physician reviewers providing clinical oversight and medical necessity reviews for health plan utilization and case management operations.
• Specialty UM Pre-authorization expertise for substance use disorder, ABA management/Autism Spectrum Disorder, MLTSS, IEP, and other specialty utilization management areas.
• Special Needs Plans (SNPs) Care coordination, provider network management, and quality measurement services for all Special Needs Plan types including D-SNP, C-SNP, and I-SNP.
• Med-Psych Care Management Proprietary interventional approach that integrates physical and behavioral health care management to positively impact both costs and outcomes for members with comorbidities.
• Population Health Tailored support in identification, engagement, and intervention for health plan population health programs targeting high-risk and rising-risk members.
• Appeals & Grievances Physician, nurse, and best-practices support for health plan appeals and grievances management, including first- and second-level clinical review.
• Advisory Services Strategic consulting engagement providing guidance for health plan operations, regulatory compliance, Stars performance, MLR optimization, and business strategy.
• Insource Partnership Dedicated comprehensive team of experienced clinical and non-clinical staff that delivers and manages health plan clinical operations end-to-end without the client bearing hiring, performance management, or training overhead.
• Staff Augmentation Flexible clinical and non-clinical staffing solutions to fill resource gaps in health plan operations across utilization management, care management, and quality functions.
• Rebellis Group Medicare Advantage Consulting Medicare Advantage management consulting — strategy, Stars ratings improvement, change management, regulatory compliance, system and process optimization, and Part D consulting — delivered through the acquired Rebellis Group brand.

Quantifiable outcome

• $1,021,792 savings generated in one month at two hospitals from admissions review converting inpatient to observation status
• +3 more outcomes

Named customers2 records

Segments5 records

Ideal customer profiles3 records

Technology focussed No

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Partnerships

Four partnerships are on record, tiered core and minor.

• Rebellis GroupcoreStrategic or Co-development Partner · 28 February 2024Rebellis Group was acquired by Toney Healthcare in February 2024. Rebellis is an expert model consulting firm founded in 2020, focused on Medicare Advantage plans offering strategy, Stars, change management, regulatory compliance, system and process optimization, and Part D consulting services. At closing, Rebellis CEO Betsy Seals was named President of Toney Healthcare and sits on the Board of the combined organization.
• TripleTree, LLCminorOthers · 28 February 2024Acted as financial advisor to Toney Healthcare, Centre Partners, and Health Enterprise Partners on the Rebellis acquisition transaction.
• Bentley AssociatesminorOthers · 28 February 2024Acted as exclusive financial advisor to Rebellis Group on the transaction.
• St. Vincent Catholic Medical Centers US Family Health Plan (USFHP)coreStrategic or Co-development Partner · 7 November 2023Toney Healthcare has expanded its partnership with USFHP to include the entire process of medical utilization management. USFHP supports approximately 13,000 beneficiaries of the Department of Defense-sponsored TRICARE Prime program in New York, New Jersey, Pennsylvania and Connecticut. The partnership now includes customer service, intake, case setup, clinical review, physician review, appeals and fulfillment.

Scale indicators7 records

Recent moves6 records

Expansion highlights6 records

Direct peers

• HealthScape Advisors: Management consultancy exclusively serving health plans and payers across utilization management, Stars, compliance, and value-based care — a near-direct competitor to Toney's managed care advisory practice with similar buyer profile and engagement models.
• Alerion Advisors: Healthcare advisory firm serving payers and providers with operational and clinical consulting — explicitly referenced in Toney's own resource library as a comparable peer operating in the same health-plan consulting niche.
• BDC Advisors: Healthcare strategy and operations consultancy serving payers, providers, and pharma — overlaps with Toney on health-plan strategy, operational transformation, and clinical program design engagements.
• SimiTree Healthcare Consulting: Healthcare consulting and talent solutions firm with strong focus on post-acute, home health, and managed care — competes with Toney on utilization management, revenue cycle/clinical operations support, and staffing services to health plans.

Broad incumbents

• Health Management Associates (HMA): Large national healthcare policy and program consulting firm with deep Medicaid, Medicare, and safety-net expertise — broader portfolio than Toney but a frequent competitor on Medicaid health-plan consulting engagements.
• Avalere Health: Large healthcare strategy and policy consultancy serving payers, providers, and life sciences with deep regulatory, Stars, and value-based care capabilities — competes with Toney on Medicare Advantage strategic and regulatory advisory work at the larger end of the market.
• The Lewin Group: Healthcare policy and management consulting firm (now part of Optum) serving health plans, providers, and government — broad portfolio but directly comparable on payer strategy, utilization, and population health engagements.
• McBee Associates: Healthcare management consulting firm serving health systems and payers with operational, financial, and clinical performance improvement — comparable to Toney on operational consulting, performance improvement, and staff augmentation for managed care clients.

Emerging players

• COPE Health Solutions: Healthcare consulting and workforce development firm with focus on value-based care, care management, and clinical workforce programs — overlaps with Toney's care management and population health service lines and its Toney Institute-style training initiatives.

Others

• Premier Inc. Healthcare performance improvement company providing consulting, analytics, and group purchasing to health systems and payers — broader and more diversified than Toney, but a comparable scale player in payer-facing performance and consulting services.

Market position

Strengths5 records

Weaknesses5 records

Competitive moat4 records

Key risks7 records

Key highlights7 records

Customer concentration

Revenue estimate

Valuation estimate

Number of profiles

Profiles3 records

Subsidiaries1 record

Funding overview

Funding rounds1 record

Investors2 records

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A1 record

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about Toney HealthCare Consulting