A surge in behavioral health utilization was driving real operating losses, but the deeper issue ran further upstream: Medicare reconciliation and provider directory workflows hadn't kept pace with the organization's growth, and no one had full visibility into where money and compliance risk were actually leaking. A cost-cutting response alone wouldn't fix that. Only mapping the workflows themselves, current state and future state, would surface where the real opportunity was.
Case Study
The losses weren’t about behavioral health, they were about processes that hadn’t caught up.
This nonprofit health plan was absorbing rising costs from a surge in behavioral health utilization, on top of ongoing gaps in Medicare Risk Adjustment and provider directory accuracy. We ran a series of Rapid Planning Events to map current and future state processes, then built the enterprise continuous improvement capability to sustain the gains.
Engagement at-a-glance
Industry:
Healthcare
Organization size:
~ 1,000 employees & Revenue of $2.72 billion in 2023.
Services:
Operations & Process Improvement
Change Management
Training & Adoption
Change Management
Training & Adoption
The Challenge
The organization didn't lack a mission. It lacked visibility into its own workflows.
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Rising utilization outpacing existing processes
A significant surge in behavioral health service utilization was driving real operating losses, adding pressure to processes that hadn't been built to absorb that kind of volume.
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Provider directory and reconciliation gaps hiding revenue
Inaccurate provider directory data and inconsistent Medicare reconciliation workflows were quietly affecting STAR ratings, HEDIS scores, and reimbursement accuracy, without clear visibility into how much revenue or compliance standing was actually at stake.
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No enterprise-wide continuous improvement capability
Process improvement work had been happening in pockets rather than as a coordinated, enterprise-wide capability, which meant the organization risked solving today's problem without building the capacity to catch the next one.
Our Approach
We mapped the workflows first, then right-sized a continuous improvement model around them.
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1
Ran Rapid Planning Events to map current and future state
We led Rapid Planning Events focused on Medicare Risk Adjustment reimbursement and provider directory data, mapping how work actually moved today against what it needed to look like going forward.
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2
Surfaced where compliance and revenue opportunities were hiding
The Rapid Planning Events gave the organization visibility into workflows like Medicare reconciliation and provider directory management that had previously been opaque, uncovering specific compliance and revenue recovery opportunities within them.
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3
Right-sized a continuous improvement framework to the organization's maturity
Rather than importing a generic model, we built an enterprise-wide continuous improvement plan calibrated to the organization's actual maturity and needs, grounded in ADKAR change management principles.
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4
Built a center of excellence to scale the capability
We created training and change management tools for the process improvement team, executives, and change champions, and stood up a center of excellence model so continuous improvement could scale beyond the initial engagement.
Value Delivered
The organization can now see where its own revenue and compliance risk were hiding.
Unlocked visibility into Medicare reconciliation and provider directory workflows
Workflows that were previously opaque are now mapped current-state and future-state, giving the organization a clear view of where breakdowns were happening.
Improved provider directory accuracy to support STAR ratings and HEDIS scores
More accurate provider directory data supports compliance standing and the quality scores tied directly to reimbursement.
Built an enterprise-wide continuous improvement framework
A single, right-sized continuous improvement plan now spans the enterprise, replacing scattered, pocketed process work with one coordinated capability.
Equipped executives and change champions to carry PI practices forward
Training and change management tools built during the engagement give the organization's own people the ability to sustain process improvement work going forward.
Results that reflect the work behind them.
$10M
Potential additional revenue unlocked through provider directory and Medicare reconciliation improvements
2
Critical workflows mapped, Medicare reconciliation and provider directory management, uncovering compliance improvements and revenue recovery
1
Unified enterprise-wide continuous improvement framework established
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