Simplifying insurance claims for pharmacies
Image by The National Cancer Institute via Unsplash
CHALLENGE
From a visual makeover to designing a user-centered digital experience
Clearing House Apothekers (CHA) is a company that handles insurance claims for pharmacies and insurance providers. CHA was looking to upgrade their claim filing software - CHA Online.
However, interviews with pharmacies and insurance providers uncovered that the opportunity to improve CHA Online extended beyond a visual refresh. A vision workshop with internal stakeholders revealed the company's drive to make a bold move that would strengthen its market position.
We reframed the challenge to redesign CHA Online to address the needs of different target audiences while updating the organization's front-end and backend infrastructures.
Vision session with stakeholders
APPROACH
Uncovering the user's mental model and seeking opportunities to drive value
Conducting interviews with different target groups - individual pharmacies, chains, insurance providers, and internal CHA users - enabled us to identify the user's goals, priority tasks & blockers.
We also identified the fundamental differences between the mental models and motivations across groups. For instance, pharmacies file claims thinking about the 'money to get back', while insurers make decisions based on the 'amount to pay'.
One critical insight was the amount of manual work that pharmacies and insurance providers had go through in order to file or review a claim. The tool was on the market for almost ten years, and its modules and functionalities were implemented individually. The experience was fragmented and time consuming.
Users had to switch from one module to another and duplicate their efforts to complete a claim filing. Small mistakes went unnoticed throughout a chain of actors and ultimately claims were rejected. Pharmacies ended up submitting the same claim multiple times; time was wasted and claim payouts were delayed.
For CHA, it meant that their tool wasn't taking advantage of centralized data and current technology that allow efficient processing of the claims.
Synthesizing user research
Modularity: finding the balance between customisation and scalability
Traditionally, CHA divided their customers in two: insurance company and pharmacies. However, these groups largely varied beyond the actor type (insurance vs pharmacy). Different size (one-man vs chain), and status (private or public) meant that users's needs and tasks for could be very different from one pharmacy or insurance company to another.
We moved the conversation from the type of audience and into the 'jobs' that different users would perform using the tool, asking ourselves what are their main goals when using CHA? what influences how they achieve that goal?. This drove us to create a modular role-based concept where users are provided with the core functionalities to support their tasks and address their motivations.
A modular solution also meant CHA would have the flexibility to evolve their pricing model, and define different packages to accommodate for customer's size an organisational structure.
Detail design and development took place in parallel with two teams working side-by-side using SCRUM: one focused on design, user validation, and frontend implementation, and the other one focused on backend development.
Overview of screens
RESULT
The new CHA online reduces errors and filing time
The new tool guides users through claim submissions. A step-by-step process allows them to focus and take one action at a time.
The team implemented a capability to recognise potential issues that would drive claim rejections and signalled them to users for corrections. This proactive approach not only reduces rejections but prevents delays in payouts.
On the other hand, the tool also allows for bulk claim submission and advanced search, which result in less time spent filing or checking paperwork.
Users had to switch from one module to another and duplicate their efforts to complete a claim filing. Small mistakes went unnoticed throughout a chain of actors and ultimately claims were rejected. Pharmacies ended up submitting the same claim multiple times; time was wasted and claim payouts were delayed.
For CHA, it meant that their tool wasn't taking advantage of centralized data and current technology that allow efficient processing of the claims.
in Berlin DE / 2022