EHR Billing System
Claims & denial in healthcare
OVERVIEW
Electronic Health Record (EHR) systems consolidate patient data, addressing the challenge of scattered information.
Administratively, EHRs are vital for Revenue Cycle Management in healthcare
They facilitate claims processing, denial handling and payment reconciliation.
WHY
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Manual claim management and payment reconciliation process are tedious and cause delays in the revenue management cycle.
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Human errors during this process results in money deduction and loss to the practiceDigitizing the process will reduce human effort, ensure financial growth to the organization
CHALLENGE
How might I create a digital streamlined process for claim and denial management and payment reconciliation in order to ease the burden of the user who has to do this manually and prevent human error?
MY ROLE
UX Research
UX Design
Visual Design
Interaction Design
Usability Testing
COLLABORATION
Self directed project
Feedback from mentors and peers
TOOLS USED
Figma
Canva
Miro
TIMELINE
5 day design challenge
DIGITAL SOLUTION
I created a streamlined AI-powered EHR billing system to simplify claims management.
It prevents denials, manages hospital finances efficiently, and enables easy payment reconciliations. Admins can also use grid view and robust filters to manage data effortlessly.
1.1 WHITE PAPER RESEARCH
How does claim & denial management and payment reconciliation work
Step 1: Claims Submission
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Admin submits claims to insurer for hospital services used by patient.
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Insurer decides whether to pay in full, partially (adjusted amount), or deny the claim entirely.
Step 2: Denial Management
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If claim is denied, Admin submits an appeal with additional information for reconsideration.
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If insurer denies the claim again, patient is responsible for paying the balance.
Step 3: Payment Reconciliation
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Claims approx ≤ (Insurer Payment + Patient Payment)
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When this condition is met, Payment Reconciliation is initiated for financial accuracy.
1.2 UI ANALYSIS
Visual UI research helped me understand best ways to display data by looking for common, interesting patterns and looking for gaps in these designs
With no access to an actual EHR system online, I relied on the available UI screens online. I was able to decide on the important columns in my data grid based on commonalities. Payment Reconciliation was not found on claim management UI screens.
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Claim scrubbing - check before claim is sent
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Denied claim tracking - Track all denied claims
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Analytics and reporting - Analyze reason for denial and report it
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Automated Appeal process - Automate process of sending an Appeal to the insurer by identifying if the claim is wrongfully denied.
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Integration with other EHR software
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Predictive analytics - To predict that a claim might be denied. To address issues before they cause a denied claim.
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ML and AI - To analyze the denial trend over a period of time and ability to learn, predict and manage the claim denied.
2.1 MVP - NEEDS ASSESSMENT
Analytics Dashboard:
Tracks total claims sent, in process, denied, and adjusted.
Provides insights for informed decision-making.
Grid Views:
Allows users to view, assess, and manage data easily.
Columns include insurer status, adjusted rate, and action options.
Supports individual column sorting and multi-select functionality
Filter System:
Employs robust filtering options for data customization.
Allows users to set custom filters for personalized views.
Denial Management:
Provides clear insights into denied claims.
Offers documentation on denial reasons.
Facilitates actions like review or appeal, with AI assistance.
Payment Reconciliation:
Automatically flags payment reconciliation status.
Alerts users for pending or past-due reconciliations.
Easy Claim Creation:
Provide easy to fill claims.
Enable user to track their progress while creating a Claim
Leverage AI in design for claim scrubbing
1.3 SECONDARY USER INTERVIEWS
With a 4 day sprint, I made cold calls on Ln, when that didn't yield results, I spoke to contacts within insurance companies to understand what was their process of rejecting claims. This helped me understand different reasons why a claim could possibly be adjusted, denied and that aligned with my white paper research findings.
Reasons for insurance to deny your claim
Incorrect information provided
Lack of medical necessity
Failure to meet certain criteria.
Prevention - Human Factors
Improve the data collection
Staff education
Automate the denial process
Review Payer Contracts Regularly
2.2 CUSTOMER JOURNEY MAPS
The customer journey maps help identify moments of truth. Especially at points of frustration, confusion.
4.1 MAKING IT USABLE TO TEST WITH CUSTOMERS
I created the mid fidelity prototypes which were used for Usability Testing. Also included this rhobust filter to manage data efficiently.
Retrospective
Key Takeaways
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Recognized further importance of understanding user needs, particularly in unfamiliar subject areas.
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Emphasized the significance of time management, prioritizing the Minimum Viable Product (MVP) and respecting time boundaries.
Future Plans
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This was a 4 day design sprint. Didn't give me the opportunity to find time to interview users to truly understand their painpoints.
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The subject is vast and there are more efficient ways to explore.
Thank you
3.1 CHARTING USER NAVIGATION
