Care Management
TABLE OF CONTENTS
The Cost of Administrative Inefficiency
The Challenge in the Real World
The Path
The Outcome
Case study
Last updated: Apr 29, 2025
Small Changes Lead to Big Impacts
The Cost of Administrative Inefficiency
Choosing the right transformation partner is critical for health plans striving to achieve efficiency and excellence. The wrong vendor decision can lead to serious challenges, including reduced productivity and heightened risks around data privacy and financial stability. Administrative inefficiencies continue to be a significant driver of rising healthcare costs, often stemming from outdated systems and fragmented processes. Recent analysis indicate that administrative spending accounts for 15% to 30% for U.S. healthcare expenditures, with at least health of this spending deemed wasteful. This translates to approximately $285 billion to $570 billion annually that doesn’t contribute to health outcomes. This represents a huge opportunity for improvement, as highlighted by an academic paper published by Humana Inc. Addressing these operational gaps and streamlining payer-provider coordination is essential to reducing administrative burdens, lowering costs, and improving the quality of care.
The Challenge in the Real World
Consider the story of one particular health plan. The plan struggled for nearly two years with a core administration platform vendor whose interface consistently failed to meet their operational needs. Their experience underscores a common challenge: the need for a reliable partner who can truly streamline operations and deliver measurable results. The health plan came to UST HealthProof with significant pain points:
Struggling to lead and implement organizational change
The health plan needs a champion to reduce operational inefficiencies and resistance across the organizationLegacy platform wasn’t working
The existing platform the plan is using causes inefficiencies and fragmented processesNavigating complex challenges
Operations were unnecessarily complex and needed to input efficiencies and processes in place to improve outcomes
The Path
Goal 1: Getting off legacy platform system
One of the biggest challenges UST HealthProof faced was transitioning the client from a complex and partially implemented legacy system within a two-year renewal cycle. The stakes were high – missing migration deadlines would result in substantial financial penalties for our client. Rather than building from scratch, the task centered on adapting the existing system while maintaining the client’s business operations and sales goals.
Our response was decisive and strategic. We developed a carefully phased migration approach with clear benchmarks and deadlines. Through close collaboration with our client, we managed each aspect of the transition while ensuring their business continued to thrive and secure major contracts.
Today, we maintain our unwavering focus on implementation milestones and protecting our client from renewal cycle penalties. This commitment exemplifies how we unburden health plans – by tackling complex challenges while they focus on growing their business.
The project remains on schedule for completion within the targeted timeframe. By implementing this strategic initiative, we will not only eliminate unnecessary renewal costs but also create a foundation for long-term organizational growth through a more streamlined and sustainable technological platform.
Goal 2: Untangle the complex operational challenges
A common misconception is that implementing a new piece of technology will instantly solve operational challenges. In reality, success requires strategic collaborative and deep industry expertise. While our health plan partner understood their platforms, our combined knowledge helped identify and implement the most effective improvements.
Change management was key to our success. By promoting a culture of innovation, our client embraced transformation at every level. While the healthcare industry has traditionally been slow to change, the rapid shifts during the COVID-19 pandemic showed that progress is achievable with a clear and strategic approach.
Organizational transformation isn’t just about implementing new technology; it’s about fostering change across the organization. “Without cultivating change, processes won’t adapt, leading to delays and budget overruns,” said Chad Kauffman, Client Success Manager. Embracing this mindset helped the client shift to an operational problem-solving approach, ensuring smoother transitions and more effective outcomes.
Our partnership’s success extends beyond the initial BPaaS implementation. The health plan also engaged UST HealthProof for additional internal initiatives like balance and controls, interface development, and expandable implementation work - a testament to our ability to deliver streamlined, effective solutions.
The Outcome
Our strategic approach delivered powerful results through steady, incremental improvements. Even when faced with unexpected challenges – including a vendor cyberattack – our robust systems kept client data secure while we adapted our implementation timeline. The impact speaks for itself. Before partnering with UST HealthProof, the health plan’s overall claim auto adjudication was below 85% but with a high resubmission from providers. That means about 80% of claims were processed without manual intervention but many still required rework. After implementing our streamlined, automated workflows the rate soared to 99.8%. This dramatic improvement reduced administrative costs, accelerated payments, and enhanced operational efficiency. Today, we continue exceed benchmarks and uncover new efficiencies during the transition. Our partnership remains strong, enabling our client to:
Maintain seamless operations
Win significant new contracts
Strengthen their market position
Build a foundation for sustainable growth
This success story exemplifies our commitment to unburdening health plans – delivering measurable improvements that drive long-term success.
