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Health Care Case Study

Case #3864: Prescription Benefits Management

A leading health benefits company required assistance with the Call Center operations of its Prescription Benefits Management (PBM) division. The PBM division had experienced double digit growth in member enrollment over the past two years and continued member growth was anticipated. The Call Center service performance levels were deteriorating and the division was unable to recruit, train and maintain skilled resources to meet the current, as well as, anticipated staffing requirements.

Questas was asked to undertake a twelve week two-tiered approach to reviewing and assessing call center operations, identifying immediate opportunities and working with leadership to improve performance.

The Questas/Client work efforts within the PBM division included two phases: Organizational Review and Assessment, and Planning and Implementation. Both of these phases were designed to achieve improved service performance while at the same time working with leadership to impart skills, share call center techniques and industry learning, and facilitate ongoing process improvement and leadership development.

Engagement Highlights

  • Industry:
  • Health Insurance - Prescription Benefits Management (PBM)
  • Client:
  • A large, publicly traded health benefits company
  • Assignment:
  • Review current operations and identify immediate improvement opportunities
  • Understand work processes, 'day to day' procedures, system performance, reporting, interaction between product areas, span of control, work assignment, workflow, quality control, performance attainment, challenges, issues and opportunities.
  • Conduct analysis of call patterns, available and required resources, talk times, abandon rates, after call wrap times, staff to work ratios and performance measures
  • Develop telephone tiering models to establish resource requirements and work with PBM leadership to develop employee skills matrices and related alignment with call demand
  • Move forward with implementation and actively work with staff and leadership
  • Maintain the project schedule and positively effect process changes
  • Engage staff in the process and follow up on changes implemented and their results
  • Duration:
  • 12 weeks


  • Developed staffing, forecasting and capacity models
  • Implemented telephone tiering to more effectively receive, route, staff and service calls
  • Developed Skills Matrices and documented process changes and recommendations
  • Simplified phone metrics and revised system reporting
  • Achieved a 13% improvement in call handle time and improved telephone service levels
  • Identified between 20% - 40% of additional capacity throughout the work week

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