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Case #4008: Administrative Simplification & Cost Reduction - Health Care, Provider and Network Management Operations

A multi-region mid-sized Health Insurance Plan was struggling with high operating costs in a period of declining membership. The Health Care Management, Provider Relations and Network Management organization was in need of more streamlined and consistent operations across regions. Health care management and utilization management practices needed to be more targeted and network contracting required greater consistency and standardization to reduce administrative costs and simplify operations.

Questas began a 6-week Assessment and Design phase that identified a range of savings and performance improvement opportunities and created a 24-week implementation plan to realize those opportunities with minimal IT investment. During the implementation, the joint Client/Questas Team worked to remove redundant and non-value added work, rationalize and improve the effectiveness of processes and quantify workloads across the division. Questas worked in close collaboration with the Client's Human Resources Department to successfully transition over 120 Associates from the organization during the course of the engagement.

Engagement Highlights

  • Industry:
  • Health Insurance and Managed Care
  • Client:
  • A Single State Multi-Region Health Insurance Plan with a Dominant Commercial Market Share
  • Assignment:
  • Rationalize and Improve Effectiveness of Health Care Management
  • Strategically Realign Division Goals and Overcome Cultural Barriers
  • Reduction of Amdinistrative Expense
  • Approach:
  • Rapid but Detailed Collaborative Appraisal of Division Performance
  • Redesign Processes to Remove Redundant and Non-Value-Added Steps
  • Streamline Organization to Eliminate Excessive Managerial Layers
  • Maintain or Improve Medical Cost Savings
  • Maximize Performance with Minimal IT Support and No IT Investment
  • Duration:
  • 30 Weeks (6-week Assessment & Design, 24-week Implementation)


  • Achieved $10.9 Million annual run rate Cost Reduction
  • Three Year ROCI at 24:1
  • Utilization Management Cost Containment Objectives Refocused
  • Case Management Program Redesigned
  • Provider/Facility Contracting Rationalized
  • Created Quality and Health Informatics Department

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