BPMN E2E Claims Mapping
Senior Researcher I Insurance I North America
PROJECT OVERVIEW
A national insurance company was facing a significant inflection point with over $200 million in outstanding payments due to medical providers.
Healthcare professionals, including doctors, clinics, and hospitals, were frustrated by the company's slow claims processing system. Delays, caused by a mix of human and technical issues, meant it often took weeks or months for healthcare providers to receive reimbursement.
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The existing claims process was excruciatingly complex, relying on a tangled web of internal systems, third/fourth-party applications, and various organizations. As a result, the user experience was both confusing and inefficient for medical professionals and insurance company staff.
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In response, the company initiated a comprehensive review of the entire end-to-end (E2E) claims process. The result was a detailed Business Process Modeling Notation (BPMN) roadmap documenting each step of the claims journey—from the moment a patient visits the doctor, to the point when the physician receives payment. My research provided a blueprint for optimizing and streamlining the claims process and got the payment pipeline flowing again.
1 study
3 months
50+ participants
Topic Areas
Ingestion of Claims
Claims Flow & Processes
Third Party Ownership
Technological Impediments
Communication Pathways
Reputation & Brand
Claim Ownership
Litigation
Political Implications
Business Objectives
Key goals of the organization
The company was facing a series of lawsuits and bad press due to an inefficient, broken claims payment system. "Unreliable" was a word being routinely thrown around within insurance and healthcare circles. The business needed uncover blockages and initiate rapid solutions.
Time-sensitive research was needed to consolidate existing claims flow maps; including meeting, interviewing, and discussing with users of the respective claims processes current issues and road blocks. Work needed to immediately begin outlining an updated E2E claims flow map that could identify major gaps in the claims flow and provide opportunities for rapid, on-the-spot improvements.
It was leadership's hope that research would lead to "unclogging the drain" of backlogged claims while reducing the amount of outstanding claims - beginning day one. Doing so would loosen the noose and lower the temperature of furious providers and healthcare organizations owed millions in reimbursement.
TEAMS & COLLABORATION
Project Manager (client-side)
Business Unit Leads
Managing Director (Healthcare)
Managing Director (Convergence)
VP, Operations
VP, Sales
VP, Finance
VP, HR/Compliance
Legal Counsel
Senior UX Researcher
UX Researcher
Tools & Software
Tools used on this project
Research Approach
With ongoing litigation, my approach pushed an extreme sense of urgency. I selected interviews and semi-usability/user walkthrough demonstrations as main methodologies - with desk and internal (client-side) research supplementing. The company was not only facing financial and legal battles, but reputational as well - as providers and healthcare affiliates grew increasingly untrusting.
Stop the bleeding.
INTERNAL MAPPING
Getting our "sea legs" was the mindset for the initial research approach.
Reviewing the mess of existing maps, flows, charts, and diagrams including documenting, reviewing, and extracting what useful information could be used to contribute to the new claims flow map, was a critical first step. Bringing teams together, making sense of the claims process, and saving precious time was foundational.
BPMN
Utilizing Business Process Modeling Notation and leveraging existing claims flow maps would allow for a master, end-to-end mapping of the entire claims process.​
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Interviews and walkthroughs with respective users responsible for flow content would allow for edits, modifications, pain points, and real time improvements to the map.
QUICK WINS
During BPMN modeling, interviews, and guided walkthroughs, a series of critical steps and inflection points would emerge.
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These points would immediately be passed along to respective stakeholders (design, development, content), to make instant changes to the system and help "unclog" the drain - allowing claims to flow faster through the pipeline.
Month 1
Months 2 - 3
Month 3
Methodologies
The research techniques used over the course of the project
Guided Usability Walkthroughs
Conducted multiple user/group interviews, used in conjunction with guided process flow walkthroughs.
1:1 User Interviews
Interviewed selected users and representatives from key business units and departments, to add granularity and detail to the claims map.
BPMN
Mapped entire E2E claims flow process through direct user interviews, walkthroughs, and confirmation sessions via business process modeling notation.
Desk Research
Conducted preliminary internal research on existing claims process flow maps, linkages between departments, connections, etc.
Data & Findings
Data captured, insights produced, and what was delivered
A complex web of technological and human dependencies.
Review of existing process maps revealed outdated, inaccurate, or misused maps within and across specific departments. Analysis was performed on a 1:1 basis with a business unit Subject Matter Expert (SME).
User interviews and guided walkthrough feedback updated existing process flows. Live, real-time input was incorporated into maps during sessions.
As live updates were incorporated into the map, data and relevant information was immediately passed along to respective business units - leading to on-the-spot improvements.
Key insights & takeaways
THIRD PARTY RELIANCE
The organization relied too heavily on outsourced tasks and processes which significantly slowed the claims flow (e.g., reliance on third and fourth parties made the claim "sit" idle).​
COMMUNICATION
Lack of interdepartmental communication lead to increased complexity and delayed processes; pitting departments against each other in "it's their problem, not ours" battles.
AUTOMATION
Heavy manual processes made the claims process extremely tedious and sluggish from a human, manual intervention perspective (due to little to no automation).
SILOED KNOWLEDGE
Siloed knowledge centers (e.g., "only Susan knows how to do this"), placed tremendous burdens on specific individuals to solve huge, organizational problems ordinarily requiring teams to remedy.
SHORTCUTS
Given the over reliance on people, those with specific knowledge possess "workarounds" only known to them (or few others) which widened the gap of what some employees knew and others did not.
MAINTENENCE
Overwhelmed employees had little time to update process flow maps when things did change. Knowledge stayed siloed or did not transfer to others. As a result, maps became outdated and inaccurate.
Deliverables
Executive leadership and business unit leads received:
Revised and updated end-to-end claims process blueprint and journey map
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25+ hours of user interviews
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50+ pages of codified data
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5 recommendations