Care Management
TABLE OF CONTENTS
How Automation Transformed a Health Plan's Operational Costs and Service Delivery
The Challenge in the Real World
The Health Plan's Pain Points
The Path
The Outcome
Case study
Last updated: Aug 1, 2025
Fixing the Foundation Case Study
How Automation Transformed a Health Plan's Operational Costs and Service Delivery
In today’s shifting healthcare landscape, plans are under increasing pressure to deliver high-quality care while controlling costs, navigating regulatory changes, and meeting rising member expectations. Success hinges on the ability to operate with precision—leveraging data driven strategies, streamlined operations, and innovative care models to maximize impact.
To navigate these complexities, forward-thinking health plans are investing in modern technology and digital transformation. In 2024, 62% of payer executives identified investing in modern technology as their top strategy to achieve organizational goals, according to a study conducted by HealthEdge. UST HealthProof works with health plans that need to improve cost efficiency, reduce waste, and deliver measurable value to members.
The Challenge in the Real World
A regional health plan, dedicated to providing quality, affordable care, faced growing challenges with outdated systems and rising costs. The plan grew quickly and had disconnected workflows and manual processes that were causing frequent claims inaccuracies, straining its ability to fully serve its community. Seeking a better path forward, it tapped UST HealthProof to modernize operations and restore focus on what mattered: their members’ health.
The Health Plan's Pain Points
The health plan approached UST HealthProof to address some pain points:
Lack of strategic collaboration from their previous vendor
The former vendor provided transactional support but lacked a proactive, strategic approach to help the health plan grow and adapt to evolving needs.
Disconnected systems with no cohesive ecosystem
The health plan’s technology platforms operated in silos, making it difficult to share data, streamline workflows, and manage member experiences effectively.
High administrative costs driven by manual processes
Without automation and integration, administrative tasks consumed significant time and resources, inflating operating costs and slow service delivery.
Poor claims accuracy and frequent operational errors
Inaccurate claims processing and system errors caused delays, rework, and payment issues, straining relationships with both members and providers.
The plan needed a partner willing to understand their unique situation and develop lasting solutions beyond just implementing technology.
The Path
UST HealthProof collaborated closely with the health plan, beginning with a comprehensive consultation to understand its specific operational and strategic challenges. Together, the teams decided to address core challenges by moving to an integrated platform centered around HealthEdge’s HealthRules Payer (HRP) platform, complemented by UST HealthProof’s Engagement Plus solution and surrounding ecosystem.
Goal 1: Enhance Operational Efficiency through Automation
UST HealthProof and the health plan strategically implemented automation technologies to reduce manual workloads in enrollment and claims processing. This focused effort aimed to improve efficiency and accuracy across key operational areas. The automation initiatives were designed to decrease manual interventions required by internal staff, allowing them to focus on higher-value tasks.
After go-live, we entered a stabilization period. UST HealthProof, in close collaboration with the health plan, methodically tracked and reviewed every aspect of the implementation during the stabilization phase. We gained a deeper understanding of live workflows and dependencies, allowing us to:
Identify where to focus efforts for greater efficiency or accuracy.
Create and present refined workflows to the health plan.
Streamline processes by eliminating duplication.
Reuse ecosystem assets for reporting and tasks.
Ultimately, this paved the way for less manual work for the health plan and for UST HealthProof. It gave UST HealthProof the opportunity to take on more manual work and free up time and money that were reallocated to focus members and providers. And UST HealthProof did this without increasing costs to the health plan. This was done through a number of automated scripts for better data matching and increasing both autoadjudication rates and accuracy.
Goal 2:Establish a True Partnership for Continuous Improvement
Technical and operational teams engaged daily with the health plan, breaking the traditional vendor-client model. Real-time collaboration, shared insights, and integrated workflows, evolved into far more than basic check-ins. Constant communication fostered a true partnership, creating a single, multi-functional team with shared goals and mutual accountability.
Because of this seamless collaboration, teams were able to jointly focus on problem-solving. Together the teams proactively identified and addressed potential roadblocks and challenges together, establishing a rapid feedback loop from day one. By the time the platform launched, most operational challenges had been addressed.
“Through regular, ongoing joint meetings, we’re able to analyze and refine the entire process,” said client success manager, Mark Jardin. “This meant we cultivated a well-informed and unified team that’s truly focused on mutual success. We made sure that every step is optimized for efficiency and impact, and all our efforts are aligned to measurable objectives.”
Goal 3:Reduce Operational Costs and Expand Capabilities
To truly transform its financial and operational landscape, the health plan aimed to reduce operational costs and expand its capabilities through targeted process optimization and automation. This strategic approach was designed to gain significant efficiencies, that would, in turn, free up existing resources for additional responsibilities.
UST HealthProof’s deep understanding of the HealthRules Payer platform was crucial. This led to the creation of specialized connectors and implementation tools, precisely designed to assess and address the client’s unique operational needs and specific pain points. The core strategy focused on meticulously improving workflows to:
Automate repetitive tasks: Reducing manual effort and minimizing human error.
- Accelerate processing times: Enabling faster turnaround for critical functions like claims adjudication.
- Optimize resource allocation: Ensuring existing staff could manage higher volumes or take on new, higher-value tasks.
Ultimately, this deliberate approach to workflow enhancement directly created the capacity for new functions without requiring additional resources, allowing the health plan to absorb growth and new demands cost-effectively.
“Beyond basic transactions, we built a collaborative ecosystem that consistently improved operations and cut total costs.”
The Outcome
Beyond basic transactions, we built a collaborative ecosystem that consistently improved operations and cut total costs. For this health plan, this partnership approach was transformative. Within the first six months of implementation, the work was paying off for the health plan:
Achieved over 90% claim auto-adjudication rate, dramatically reducing manual processing time
Maintained high claims processing accuracy while reducing staff workload
Decreased administrative costs through streamlined, automated workflows
Created capacity to absorb new functions like high-dollar claims audits without additional resources
The UST HealthProof implementation team successfully resolved approximately 75% of identified operational challenges during the initial implementation phase, with an additional 10% addressed during the post-launch stabilization period.
The automation initiatives substantially decreased manual interventions, allowing staff to focus on higher-value tasks. As workflows improved, UST HealthProof took on new responsibilities within existing resource allocations, further reducing the health plan’s total cost of ownership.
These successes led the plan to renew its initial contract. The renewal expands services to include claims audit and workflow optimization using existing platform capabilities, without increasing costs.
With operational stability in place, the health plan has shifted its focus to enhancing member and provider experiences while continuing to advance its mission of delivering quality, affordable care.
