Q&A: Where Should Health Plans Start With Operational Optimization?

In our previous Q&A, we explored a question many payer organizations are asking today: Is your health plan getting full value from its core systems?

For many health plans, the answer is not a simple yes or no. Operational performance exists on a spectrum. Most organizations have areas that perform well alongside workflows that could be improved through better governance, more consistent metrics, or fuller adoption of existing platform capabilities.

Once opportunities have been identified, the next question becomes: Where should we start?

We recently sat down again with Tegria Managing Director Gary Mirka to discuss how health plans can approach operational optimization in a way that delivers measurable value while remaining manageable for operational teams.

Q: Once a health plan identifies opportunities for improvement, where should it begin?

One of the most common mistakes organizations make is trying to improve everything at once. Health plans often have opportunities across multiple operational areas, from claims and enrollment to provider configuration and prior authorization.

While it can be tempting to launch a broad initiative, Mirka recommends starting with a specific workflow or operational domain. “I generally like to start with a specific workflow or operational area,” he said. “Something like prior authorization, coordination of benefits, or a particular configuration process.”

A focused approach makes it easier to define objectives, engage the right stakeholders, and measure progress. It also helps organizations demonstrate value more quickly.

Q: Why is a narrower focus often more effective?

According to Mirka, operational improvement efforts are most successful when they are tied to a specific business outcome. For example, an organization may be experiencing delays in onboarding new employer groups, excessive manual review of coordination of benefits claims, or challenges maintaining claims payment accuracy. Each of these issues can be examined individually and improved through a structured process.

“When you focus more narrowly, it becomes easier to measure outcomes, build momentum, and help teams adopt changes successfully,” Mirka explained. A targeted initiative also helps avoid overwhelming operational leaders who are already balancing day-to-day responsibilities with ongoing regulatory and business demands. 

Q: What should health plans evaluate before selecting a focus area?

Mirka recommends starting with performance metrics. One of the first questions he asks clients is how they currently measure operational performance. In many cases, organizations have strong anecdotal awareness of pain points but limited visibility into the metrics behind them.

Examples may include:

These measures can help identify areas where operational improvements are likely to have the greatest impact. “If you don’t have visibility into performance, it becomes difficult to understand where inefficiencies exist or where improvements can create meaningful value,” Mirka said. 

Q: Should optimization efforts focus on technology, process, or people?

The answer is usually all three. Technology often receives the most attention because it is visible and measurable. However, many operational challenges stem from the interaction between systems, workflows, and governance practices.

Mirka frequently encounters organizations that have current software versions and access to robust platform functionality but have not fully operationalized those capabilities.

“In many environments, the technology itself isn’t necessarily the issue,” he explained. “The challenge is making sure teams have adopted the processes and workflows that allow them to take advantage of what’s available.”

This is one reason workflow-focused optimization can be so effective. It creates an opportunity to examine technology, process, governance, and operational practices together.

Q: How can health plans avoid overwhelming their teams?

One of the most effective strategies is to think in phases rather than treating optimization as a one-time project. Mirka encourages organizations to focus on achieving meaningful improvement in one area before moving to the next.

“I like the idea of smaller initiatives that build momentum,” he said. “You solve one problem, demonstrate value, and then use that success to identify the next opportunity.” 

This approach helps teams stay focused while creating a sustainable path for continuous improvement. It also provides leadership with tangible evidence of progress, which can strengthen support for future initiatives.

Q: What advice would you give payer leaders who are deciding where to start?

Start with the business problem. Look for areas where operational friction is affecting performance, increasing administrative effort, or creating challenges for internal teams. Then examine the metrics behind those issues and identify opportunities where improvement can be measured.

Organizations do not need to transform every aspect of their operations at once. In many cases, the greatest value comes from addressing one workflow, one process, or one operational challenge at a time.

“The organizations that see the most success are often the ones that can clearly define the problem they’re trying to solve,” Mirka said. “Once you understand the problem and establish the right measures, it becomes much easier to improve performance.” 

Looking Ahead

Operational optimization is most effective when it is guided by clear objectives and measurable outcomes. By focusing on targeted improvements, health plans can build momentum, strengthen operational performance, and create a foundation for long-term success.

In our next Q&A with Gary Mirka, we’ll explore the role of governance and operational metrics and discuss how health plans can measure the impact of optimization initiatives over time.