Case Studies

Effective methodology selection delivers project success

AmeriHealth Administrators is a full spectrum of business process outsourcing (BPO) and self-funded health plan administration services. The organization is powered by a culture that is nimble, adaptive, and relentlessly dedicated to solving problems from the ground up.

AmeriHealth Administrators has experience managing more than $1 billion in health benefits to help insurers, employers, producers, health care providers, and members thrive.

AmeriHealth Administrators have nearly 80 years of health care industry experience, and more than 500 employees with expertise ranging from cost containment and regulatory compliance to specialized processing services and self-funded health plan management.

Background: The program was to implement HealthEdge (HE) solution, a health insurance core processing system. The program involved HealthRules implementation, portal integration, training, and calibration.

The program’s scale required that certain elements be managed by Agile methodology, while others worked well with Waterfall methodology. The total program budget was over $4 million, with very a tight timeline due to the enrollment season’s impact. The implementation of this system affected all aspects of the organization’s business delivery.

Challenges: The program’s scale and use of multiple methodologies required a seamless integration of implementation outcomes to ensure program success.

Solution: ORI conducted an assessment to determine the vendor’s capabilities and limitations, the client value stream, and project management methodologies. Though the HealthRules implementation required elements of an agile approach, ORI determined that a hybrid Agile – Waterfall approach was best for integrating HealthRules, the HealthEdge Portal and HP Exstream.

As referenced earlier, AmeriHealth Administrators’ knowledge of Agile was minimal and the program timeline was short. Introducing a new approach to an already difficult and robust program was very challenging and needed a delicate strategy to ensure success. Knowing how to work with different teams within the program to leverage each methodology’s strength was critical for the program’s success.

Results: The correspondence interface HP Exstream implementation was completed ahead of schedule. The executive management team appreciated the effectiveness leveraging multiple methodologies and integrating them seamlessly. The program proved to be a success that exceeded expectations.

Key to Success: ORI’s experienced Sr. Project/Program Delivery Manager/ Adviser was able to assess and understand the organization’s capability and needs. Our ability to leverage the strength of different methodologies and adapt them to the client’s unique needs delivered a successful outcome. The ability to leverage thought leadership was essential in enabling buy-in of key stakeholders.

Delivering Project Success through Effective Process Improvement

Alegeus is the industry’s largest and most comprehensive consumer healthcare funding platform. It supports more than 30 million consumers and 225,000 employer groups. It processes more than $9.1 billion in healthcare payments annually, with 15.3 million active payment cards. Alegeus services more than 40% of the benefits accounts in the market.

Background: The TPA training and integration project involved onboarding one of our largest clients at the time, providing training, and integrating their correspondence fulfillment vendor.

Challenges: TPA training and integration project for a large client was a relatively new service; hence there was no process in place to handle the complexities of the integration. It was a high-visibility project that would help establish future growth.

Solution: ORI’s assessment determined the value stream, the vendor’s capabilities and limitations, as well as client and project management methodologies. The results showed that tools from the Waterfall approach were adequate for the project.

There was also a need to create a process that allowed direct communication with the development team, without distracting the team from its core focus. Instead of maintaining the current process of having the Project Manager be the middleman/woman reviewing and validating the customer’s technical needs, the development team was engaged much earlier. The new process of leveraged templates and questionnaires, and it limited client-facing events involving the development team. The integration process was improved by 10%, allowing the implementation to be completed much faster and much more reliably. The new approach received recognition and awards for the quarter.

Results: The project proved to be very successful, and the new process was used for future complex projects going forward. All the project’s objectives were met. Involving developers earlier in the project (before implementation) allowed for better communication and support.

Key to Success: Experienced Senior Project/Program Delivery Manager/ Adviser ability to assess, understand the organization, as well as customer capability and needs. Also, the ability to leverage effective facilitation, communication, thought leadership, and oversight drove the project to a successful outcome. The ability to adapt project management tools to the organization’s need was also critical.

Improving Project Delivery in an Ever-Changing Regulatory Environment

Blue Cross and Blue Shield of North Carolina (BC NC) is a fully taxed, not-for-profit, North Carolina health insurance company with major operations centers in Durham, Fayetteville, and Winston-Salem. There is an office in Charlotte. BCBSNC employs more than 4,700 North Carolina residents and serves more than 3.89 million customers.

While program management is important for aligning an organization’s projects with its strategic goals in any industry, it is much more critical for large health insurance companies in the highly regulated and changing world of healthcare.

Several project managers work in the PMO and are responsible for executing projects, including compliance, risk mitigation, technology upgrades, and process improvement.

In 2009, a new healthcare reform law required that health insurers implement changes in order to comply with the new regulations. This kicked off a series of changes, during a seven-year timeframe, where multiple government agencies were creating new policies and revamping old policies.

This dynamic environment created a lot of challenges for program management, due to the overwhelming number of stakeholders and a constant changing of project scope. An innovative approach was needed for a highly visible program called the HCR program.

Background: HCR was a multiyear program with 13 projects and a budget of approximately $6 million. It focused on assuring compliance with CMS regulations. In 2014, when the ORI team became involved in this program, HCR had previously gone through five program managers, with a $900,000 program management overhead cost (21% of the program’s budget).

Challenges: HCR was a compliance-driving program with high visibility because of its significant financial impact, high potential for loss of members, negative media reporting, and the overtaking of customer service support during the critical enrollment season.

Solution: Assessment determined the vendor’s capabilities and limitations, and client and project management methodologies was conducted. The assessment’s result revealed that tools from the Waterfall, Iterative, and Agile methodologies were needed to effectively manage different aspects of the program.

To ensure the project’s success, ORI included an experienced Senior Program Manager to create an effective communication strategy, a good value delivery strategy, and optimal team composition. We streamlined the overall program management overhead structure to ensure that the right experience level was aligned to roles.

We quickly realized that the original overhead mix created redundancy, resulting in a $270,000 savings. A more effective war room was created to better facilitate engagement with key stakeholders.

Results: BCBSNC’s CEO recognized the HCR program as one of the most successful programs at BCBSNC in 2014.

Key to Success: ORI assigned an experienced Senior Project/Program Delivery Manager, and focused on value delivery, task alignment and right sizing the program team. This allowed for program success and cost reduction.

Deliverable Project Success through Effective Assessment of Vendor Limitations, Capabilities and alignment with Organizational Timeline

Tufts Health Plan is a nonprofit organization founded in 1979. It is nationally recognized for its commitment to providing innovative, high-quality health care coverage. The plan offers members and employers an array of health management programs, which support evidence-based approaches to health and wellness.

Tufts Health Plan is one of the few health plans in Massachusetts to participate in commercial, as well as Medicare and Medicaid-subsidized markets, offering coverage across the life span regardless of age or circumstance. With headquarters in Massachusetts, Tufts Health Plan also serves members in New Hampshire and Rhode Island.

Tufts Health Plan is a leader in advancing public policy discussions on several issues: prevention and wellness, affordability, and removing obstacles to accessibility.

Background: The Diamond Upgrade Program was a $1.5M multiyear program with the goal to Upgrade Diamond database technology, Upgrade Diamond application, and upgrade hardware to titanium servers. This program would increase Tufts Health Plan’s capacity to develop new web screens and data for internal and external services and to provide real-time updates on its provider and member portals. It would also allow Tufts Health Plan to take advantage of capabilities such as self-service reporting by operations and analytic groups. Implementing this project would help reduce cost over the short to medium term.

Challenges: The Diamond Upgrade Program was mostly a technology upgrade-driven program; hence the stakeholders were well defined. The challenges stemmed from the fact that the existing application was written in a highly customizable language that wasn’t supported. It needed to be upgraded to a Java-based application with limited in-house Java experience. The application upgrade depended on a vendor that turned out to be unreliable. The program timeline was significantly shortened because it started late.

Solution: We conducted an assessment to determine capabilities and limitations of the vendor, client value stream and best project management methodologies for this program. The assessment showed that the Waterfall approach was an adequate approach for this program. It also showed that, because the timeline was critical, the best course of action was to effectively reduce risk and have contingencies in place to ensure minimum impact on the program timeline.

The two significant risks ORI identified were: 1) ensuring data integrity was maintained during the transformation and ensuring that vendor was able to start and complete their work on time.

The assessment of the vendor concluded that they did not have resource bench depth to quickly and effectively support the program needs. We decided to bring on a developer with some experience in the customized language for current production support. This resource would also need to learn the JAVA-based application for the future state.

At a critical point of the program when we needed to start engaging the vendor, they informed us that they would need several months to ramp up before being able to support our needs. Because we assessed the potential for this risk early, we were able to quickly change direction, use the one developer we brought on early, while leveraging the vendor in a consulting role. This approach allowed the program to be completed on time with a $500,000 savings. The data integrity risk was mitigated by creating a unique testing approach that was quicker and delivered consistent results.

Results: The program proved to be very successful at THP. The program had budget savings of $500,000 with all objectives of the program exceeded. Bringing in a developer earlier instead of waiting for the development phase allowed for quick recovery of a potentially disastrous outcome.

Understanding how to better align project resources (internal and vendor) to mitigate potential risk was critical to the successful outcome.

Key to Success: Experienced Sr. Project/Program Delivery Manager/ Adviser with the ability to assess, understand the clients value stream, the organizations and vendor capability and needs was critical. The ability to leverage effective facilitation, communication and thought leadership drove the program to a successful outcome.