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Accessing Medicare Claims Data within Days, Not Weeks
I was the Senior UX Researcher and Human Centered Design Lead on this project. Together with healthcare innovators on a mission to transform the way Medicare data was accessed and utilized. Our vision: granting healthcare providers real-time access to critical Medicare claims data within 2-4 days, a game-changer in the realm of patient care coordination. Let me walk you through our remarkable journey.
The Dream Team
Our squad was a powerhouse of talent, consisting of a Program Manager, Project Manager, Technical Lead Developer, Two Senior Developers, Data Analyst, Subject Matter Expert, and yours truly - the Senior User Experience Researcher and Human-Centered Design Lead.
My Role: Bridging Insights and Innovation
As the Senior User Experience Researcher and Human-Centered Design Lead, I wove together a narrative that interconnected research, user insights, and the welfare of beneficiaries. I delved deep into user pain points, aspirations, and collaborated closely with Medicare developers to illuminate the problem and offer a revolutionary solution.
The Hurdles We Overcame
Our path was not without challenges. User access, client control over the user experience, and the time constraints of healthcare professionals were formidable barriers to surmount.
The Game-Changing Solution
Our answer? We developed a live data feed, drastically reducing access time from a staggering 25-30 days to a mere 2-4 days. This quantum leap in data accessibility was a shot in the arm for care coordination, especially for patients with chronic conditions.
Our Method: Research, Refinement, and Results
Our methodology was a carefully orchestrated symphony of researching data fields, dissecting raw data feeds within Medicare, understanding user workflows, and empathizing with their needs and pain points.
Metrics of Triumph
Our research yielded metrics that painted a clear picture of success. We created a pilot product that proved invaluable to approximately 130 users in a specific Medicare payment model. Our groundbreaking work paved the way for Medicare to give the green light for production in May 2023.
Empowering Medicare Providers expedite payments
Our mission was rooted in a simple but profound need - Medicare healthcare providers required current data about their patients. How could we give these users access to Medicare claims data sooner? What data fields were pivotal for their patient care success?
Shortening the Data Lag
Until recently, Medicare data was accessible only 3-4 weeks after a claim submission. We ventured to change this narrative.
Our users were Accountable Care Organizations (ACOs) from a variety of payment models within Medicare. We demonstrated to Medicare that access to claims could greatly improved care coordination and outcomes.
Our team created an enhancement to an existing Application Programming Interface (API) platform.
We answered these questions:
What system do we use to give users access to claims data?
What data fields do users need to make timely analysis about their customers?
The Benefits of Speed
Accessing data swiftly bestowed several gifts upon healthcare institutions:
Coordinate Beneficiary Care: Faster access to information allowed seamless care coordination.
Expedite Payments: Timely data meant quicker reimbursement for services.
Track Out-of-System Care: The ability to track external care enhanced patient safety.
Improve Clinical Context: Real-time data enriched the clinical context, leading to better-informed decisions.
Downstream Payment Cost Savings: Early data access translated to cost savings further downstream.
Claim Rejection Mitigation: Getting ahead of claim rejections reduced administrative hassles.
Track Financial Performance: A holistic view of financial performance became attainable.
Shaping Medicare's Future
Our research, analytical prowess, and engineering innovations changed the game for Accountable Care Organizations (ACOs) under various Medicare payment models. We demonstrated to Medicare the pivotal role of early access to claims data in enhancing care coordination and patient outcomes.
The Power of Enhancement
Our team amplified an existing Application Programming Interface (API) platform to achieve these remarkable results.
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Answering Critical Questions
We navigated complex questions:
The Right System: What system would give users access to claims data?
Data Fields for Analysis: What data fields were essential for timely customer analysis?
Part 2: Claims Phases Diagram (below)
I visualized intricate data from different phases of the Claims Adjudication Process, simplifying complexities for Medicare stakeholders. This visual aid was pivotal in conveying the significance of early data access.
Claims Phases Diagram
My colleague gave me an Excel file illustrating specific data that was populated in each Phases of the Claims Adjudication Process. I created a visual to explain it. This helped Medicare stakeholders understand what happened in each phase of the data and what user would see with early access to this data.
Research Goal #2
Field of Dreams
Our quest was twofold: identifying the data fields essential for Accountable Care Organizations and highlighting vital case studies aligned with their business objectives.
We dove deep into user interviews, contextual research, and surveys, unraveling the data fields crucial for patient care and provider communication.
User Engagement: Fostering Community and Knowledge
I orchestrated surveys and designed webinars, fostering user engagement, and unearthing the data fields different users leveraged.
Onboarding and Participation
I created comprehensive onboarding documentation and a Participation Guide, ensuring a smooth transition into the new data enhancement.
Prototyping for Progress
Our team developed prototype dashboards for user testing and eventual standardization.
At the end of our pilot, I interviewed users, gaining invaluable insights into their interactions with the data and the transformative impact on their workflows.
We measured tangible outcomes:
Data Access Time Reduction: From 30 days to 2 days, a revolution in data accessibility.
User Adoption: A commendable 30% user adoption rate as of May 2023.
Provider Empowerment: Enhanced patient care coordination and outcomes.
Cost Savings: Downstream payment cost savings and reduced administrative burdens.
Use Case Illustrations
I created various illustrations for use case dashboards. Below is one example.
These prototype dashboards I created not only to illustrate a use case, but to use to test with users to eventually create a standard dashboard.