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Payer Operations

Improving effectiveness, efficiency, service performance, and future capabilities for healthcare payers

We combine advanced tools and techniques with expertise in operations to help payers boost their operations and implement strategies that will stand the test of time. Our work helps payers address four imperatives:

  • improve the quality of care and service for all stakeholders through more efficient and less error-prone operational processes
  • deliver better experiences to patients and providers—for example, through use of self-service tools and improved customer service during direct interactions with members
  • develop the future-state operations strategy and define the capability needs—for example, through use of automation and digitization to reimagine traditional processes using emerging technologies
  • optimize the purchasing strategy and outside spend—for example, through leveraging of labor mix using a combination of business partnerships, outsourcing, and captive strategies

What we do

Optimized administrative-cost spend and greater return on investments

We help plans develop capabilities and deliver superior customer experience while optimizing administrative spend. We also help them identify areas of opportunity within the payer value chain to get a fuller view on where to optimize costs and where to enable funding of other parts of the value chain that need advanced capability.

Digitized operations, with a focus on technology enablement

We help payers fully leverage the opportunities of next-generation tools, analytics, digital penetration, and cognitive automation to improve productivity, quality, and customer experience. Through digital technologies, we deliver faster turnaround times for approvals and claims payments, proactively anticipate member and provider needs to improve stakeholder experience, and streamline care management operations to drive increased healthcare value.

Operating-model strategies, capabilities, and improvement programs

We work with payers to develop specific actions and interventions that address the known gaps in capabilities and processes. Furthermore, we help payers set up governance structures to ensure an execution-focused mind-set and drive accountability. Our transformation playbooks help foster a culture of continuous improvement and an agile mind-set within the organization by helping the workforce gain appropriate skill sets and matching talent to value.



in claims errors through improvement of provider-directory accuracy



in write-offs from errors in setting up benefits during the enrollment process



in administrative per-member-per-month cost through use a multilever approach

Featured capabilities

We offer payers a wide range of innovative tools and capabilities.

Comprehensive assessment of current-state capability: Proprietary methodology using our payer-value-chain taxonomy allows us to conduct a granular capability assessment across all functions and subfunctions to identify capability gaps and the potential impact of addressing the identified gaps.

Operational key performance indicators: We use a detailed set of financial, operational, staffing, and utilization metrics from more than 35 organizations, segregated by business segments, to identify cost-optimization opportunities and drivers of variation in functional performance rapidly.

Strategic roadmaps: We help payers conduct rapid ideation and create effective governance structures—as well as enable rapid execution on identified opportunity areas. We also leverage a repository of more than 350 interventions, spanning all general- and administrative-cost areas, administration functions, and subfunctions of the payer value chain—each with implementation best practices, valuation methodologies, milestones, and key performance indicators for rapid deployment.

Examples of our work

Process- and organization-redesign program for a payer organization

We designed and launched interventions (for example, automation of claims intake) to improve a payer’s operational performance dramatically and build internal capability. We also helped redesign the organization to support the new operating model, with increased accountability from functional leaders and a continuous-improvement mind-set.

Identification of operational-expense savings through a rapid diagnostic

We launched a rapid diagnostic to identify areas of spend growth across an enterprise and designed interventions worth $310 million in net impact to improve operational performance and customer experience.

Spend evaluation and intervention design for a payer’s procurement organization

We reviewed a payer’s entire procurement spend to identify areas of opportunity, implemented interventions worth $350 million, established regular processes, and built capabilities within the procurement organization to lead further implementation.

Connect with our Healthcare Systems & Services Practice