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Case #9940: Health Care Maintenance Organization – Network Operations and Care Management Service Improvement and Cost Reduction

The Health Care Maintenance Organization (HCM) of a leading Not-for-Profit Health Insurance Company was not meeting expected performance levels. Costs were high and processes were inconsistent from desk to desk and across locations. Decision making was slow as a result of excessive organizational levels and a non-functional organizational structure which encouraged redundant functions.

We were called upon to review and help improve the processes within Pre-certification and Review, Disease Management, Case Management, Credentialing and Provider Database.

After completing a six week Assessment and Design (“A&D) phase which identified a range of improvement opportunities and attendant benefits, a joint team implemented substantive changes over a six-month implementation period.

These organizational and process changes resulted in improvements in turnaround times, inventory levels, call handling and disease, case and care management practices. Overall administrative cost savings were realized in excess of $6 million annually.

Engagement Highlights

  • Industry:
  • Health Insurance
  • Client:
  • A Leading Not-for-Profit Health Insurer
  • Assignment:
  • Reengineer Processes and Reduce Administrative Costs
  • Improve Quality and Cost of Care
  • Develop Metrics, Reporting and Staff Models and Quantify Workloads
  • Flatten the Organization
  • Approach:
  • Assess the Current Organization and Identify Greatest Opportunities
  • High Client Participation and Ownership for Improvements
  • Improve Service and Maintain or Improve Accuracy of Processing
  • Reduce Non-value Added Activities and Redundant Tasks
  • Set Reasonable Expectations and Improve Spans of Control
  • Duration:
  • 32 Weeks (6-week Assessment & Design, 26-week Implementation)


  • Achieved Annual Savings in Excess of $6 Million
  • Credentialing Throughput Increased 54%
  • Provider File Backlog Decreased by 83%
  • Field Personnel Reduced 32%and Increased Visits Per Day By 62%
  • Maintained or Improved Overall Processing Accuracy
  • Span of Control Increased from 6.8 to 10

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