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Health Care Case Study

Case #3947: New System Implementation - Claims, Customer Service, Member Service and Healthcare Management Operations

A leading Health Insurance and Managed Care company had acquired several other complementary Health Insurance and Managed Care companies. Once the acquisition was completed it was decided that in order to achieve the economies of scale expected from the acquisition, many of the Legacy Information Systems would have to be consolidated into a select few.

The regional President asked us to help leadership improve overall productivity, assist in achieving a budget neutral position for re-systemization and help create an infrastructure, transfer of skills, tools and models during implementation. The scope of the initiative spanned Claims, Customer Service, Member Services and Healthcare Management

Engagement Highlights

  • Industry:
  • Health Insurance & Managed Care
  • Client:
  • A Multi-state Region of a Leading Insurance and Managed Care Company
  • Assignment:
  • Close the gap between current legacy system and re-systemization performance
  • Establish Baseline measurements of Claims Resolved per paid FTE, Inquiries Handled per paid FTE, Groups and Members per paid FTE
  • Increase the number of Claims Resolved per paid FTE
  • Improve Multi-state processing on new systems reflected by 'cost avoidance' as old legacy systems are converted
  • Improve training curriculum and consistency of documentation, definitions and development of the infrastructure for re-systemization, ownership and perpetuation of implementation skills through tools and knowledge transfer
  • Approach:
  • Detailed Appraisal/Accelerated Implementation
  • Embrace and Integrate Previously Existing Initiatives
  • Build a Management Team Focused on Shared Business Objectives
  • Establish Clear Ownership/Responsibility Relationships
  • Design Standard Metrics and Uniform Management Reporting Systems
  • Duration:
  • 44 Weeks


  • Development of Claims, Customer Service and Member Service baselines, staffing models and migration models
  • Assistance with training curriculums, development and documentation of infrastructure tools and ongoing development of reporting necessary to monitor the migration and achieve a mature processing state
  • Over 1.5M member lives migrated to new system with over $10M in annual savings
  • Employee productivity improved by over 50% compared with initial migration state and new system combined auto-adjudication rate improved by over 20 percentage points
  • Five legacy processing systems replaced by a new system and virtual processing increased in place of employee processing

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