Improving claims submission and automatic processing
BACKGROUND
Premera Blue Cross is a not-for-profit health insurance company. It provides health benefits to over 2.5 million people nationwide.
This project aims to understand the end-to-end customer-submitted claims processes and explore improvement areas.
*Due to confidentiality, this project will not disclose any specific details
My Role
Lead Researcher
Who I worked with
Product Designer, CX strategist and stakeholders from IT and Operations
Project Duration
10 weeks
PROBLEM
Customers are confused about how to submit health claims online. Incorrect submissions hinder automatic processing and reduce customer satisfactions
PROCESS
Initial discovery: We lacks an understanding of the end-to-end claims process
I began with background research to understand why customers struggle with the online claim submission flow. I discovered that claims pass through multiple touchpoints, each impacting the customer experience. However, there’s limited understanding of the end-to-end process. To provide actionable recommendations, I focused my research on clarifying the internal claims process and identifying the required information for successful submissions.
Research Questions
Understand the internal process of customer-submitted claims
How are claims processed internally?
Which teams are involved in the process?
Identify gaps in the current process and explore opportunities to improve the customers’ experiences
What pain points and needs do internal teams have?
How is the current process affecting our ability to serve our customers?
Further understanding: Subject-Matter Experts(SME) Interviews
To gain understanding, we reached out to subject matter experts in the company and conducted semi-structured interviews with them. We hope the interview can clarify the internal processes, what tools internal teams use, and what pain points they have.
Finding the right person to talk to within the constrained timeframe was not easy
Due to the time constraints, I partnered with designers and strategists to conduct the interviews. Before each interview, we prioritized questions and sorted the questions by themes (e.g., general questions, design questions, etc.) to ensure we could efficiently learn from the subject matter experts.
DATA ANALYSIS
Why Service Blueprint?
Since we tailored the interview questions based on the participant’s role and the part of the process they were in, the interview data was scattered. I decided to develop a Service Blueprint to synthesize the data, where I identified the end-to-end internal process, cross-department efforts, and based on the findings provided recommendations for service improvements.
The blueprint represents the initial and final understanding of the process:
KEY FINDINGS & RECOMMENDATIONS
The interview helped us confirm the information about customers’ struggles and pain points around submitting and waiting for claims experiences, it also added a new understanding of how the current process is inefficient and costly for the organization. This insight helped us to provide actionable recommendations and next steps to improve the internal and external experiences.
Confirmed findings:
Customers struggle with the online submission process. Frustrated customers called and increase call center volume.
The increased customer-submitted claims during the Covid-19 pandemic increase the claim’s processing time.
New findings:
The online customer portal lacks guidance on how to submit a claim, customers make errors.
Incorrect submission causes claims sendback, and each sendback is $costly
There is a mental gap where customers submit claims digitally and receive a letter sendback letter
Recommendations
Submission stage
Improve up-front data capture to increase the quality of data entering into the system
Set expectations on how long the claim takes and how will we reach out
Improve visibility of system status, for example, provide a submission history list with reference number, date of submission, date of service, and total charge
Claims awaiting stage
Explore communication channels to notify customers that claim is received or sendback
Provide directions on how to submit missing information and if the information is accepted by Premera
IMPACTS & LEARNINGS
Impacts
Clarifies and visualizes the complex internal process for the team
The service blueprint identifies which departments and teams are involved in the process, how they work separately or together.
Services as a guideline for designers, researchers to evaluate and improve customer experience
A resource to onboard other teammates to claims-related projects and helps teammates identify communication and operation gaps within the claims workflow.
The service blueprint can be iterated over time, the ability to add metrics and other criteria to measure implemented changes
LEARNINGS & REFLECTIONS
Learn a problem from multiple perspectives. Even though it might seem like a linear process, many factors play in a problem. Therefore, it is important to learn as much as possible and understand different perspectives before diving into the problem.
Always communicate with teammates and stakeholders, share knowledge and resources within the bigger project. Many of us are working within the same space, it is important to share our learnings along the way and prevent working in a silo.
Manage research timeline and resources properly, set realistic expectations. At the very beginning, I set an ambitious timeline with the goal of reaching out to the ideal participants to inform research. Throughout the research, I have encountered barriers in finding participants and utilizing resources within the time frame. I learned that there could be trade-offs in research and it is important to manage them properly.