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Health Care Case Study

Case #12010: Provider and Network Services Process Improvement

A national health benefits organization was looking to improve the infrastructure of their dental organization in order to better position for planned Merger and Acquisition activities and significantly expand their business market share. Our client was planning to double their member base and achieve the position as one of the top 5 dental organizations in the country. Questas was engaged to help prepare the organization for this growth and help build an infrastructure to handle this almost 100% increase in dental membership.

Engagement Highlights

  • Industry:
  • Health Insurance
  • Client:
  • A National For-Profit Health Benefits Organization
  • Assignment:
  • Assess the current state of the dental organization to include: staffing levels; capacity plans; resource alignment; reporting; metrics; performance levels; and the infrastructure required for growth
  • Establish a single provider repository for provider data and a contract repository with on-line viewing capability
  • Streamline and improve the credentialing process
  • Redesign provider and network processes to increase accuracy and timeliness of processing for incoming provider contracts, changes and terminations
  • Improve the dental organization’s infrastructure improved service and growth
  • Approach:
  • Conduct and participate in daily meetings with client leadership and associates to develop and implement changes in workflow, processes and management practices
  • Communicate all key changes during regular operations meetings
  • Quickly implement an inventory reduction plan to reduce backlogs and stabilize service while in parallel developing the infrastructure required for growth
  • Align resources based on work volume; introduce performance monitoring and performance management techniques
  • Instill and cultivate a bias toward action
  • Duration:
  • 4 months


  • Developed processes, procedures, workflows, staffing models, reporting and infrastructure to position client for growth
  • Redesigned contract entry to eliminate duplicative entries in multiple systems
  • Participated in and provided oversight for data cleanup and synchronization
  • Participated in and provided oversight for the development of an on-line contract repository

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