DRG Claim Auditing

Prepared for:

The Challenge

Zelis, an industry leader of healthcare payer and provider servicing, needs to support a growing line-of-business that audits DRG (Diagnosis Related Groups) Claims. To succeed, they’d require an intuitive application that offered some current app familiarity to their users. Much of the work auditing a DRG is currently performed within a thick desktop client, which they call a ”training nightmare” and would prefer a scalable web-based client.

After finding the team at Zelis to be rooted in traditional waterfall processes for product delivery, we recognized an opportunity to introduce change management for the benefit of the overarching organization.

The Results

As a result of understanding the user and business, our team was able to provide a successful self-checkout experience that led to

35%

Reduced Reduced customer checkout time checkout time

Yearly revenue increase with shorter wait times

42%

Reduced workforce resources cost for customer service/support during the self-checkout process

The Team

Product Sponsor

UX Director

UX Lead

UX Designer

Business Stakeholders

Architects

Developers

Business Analyst

Project Manager

Deliverables

Enterprise Design System

UX Research

UI Design

Interactive Prototypes

User Accepted Backlog Requirements

The Process

Discovery & Observation

Understand the Business

We hold in-person kickoff meetings to learn the history of the product, and what they know about the problem space and their user base.

Business Goal Identification

More Audits in Less Time

A major metric of success was weighted upon increasing the users’ daily audit numbers, as well as their accuracy.

Allocation Transparency

Managers would need the ability to view the number of claims each user was responsible for to adjust as needed.

Rely On The MAYA Principle

We would need to pay homage to a legacy system to ensure its users felt at home, while also providing a fresh, intuitive experience.

Understand the Product

To better understand the existing product we document the information architecture, and evaluate the design.

Product Features Identification

Effective

Each user-type had unique needs within the UI. By instilling a role-based system, each role could have specific features and functions.

Concise

Data-heavy applications must be created with cognitive load limitations in mind and keep the information displayed concise and obvious.

Prioritized

Providing a model for proper information hierarchy would be a paramount consideration when crafting the enterprise design system.

Understand the User

In order to gain insight into the user needs, we visit business locations and ask users about their experiences.

User Insights & Feedback

Wants

Users sought an interface that displayed a maximum amount of information in a minimal amount of real estate.

Pain Points

The complex flow of the current app caused a multitude of training issues and got in the users’ way while performing their duties.

Behaviors

Users were being forced to learn and remap their actions due to the lack of consistency across various enterprise applications.

Refine the Findings

Utilizing our research, we refine and solidify the project’s focus to better align with business goals and user needs.

Refining Initial Insights

Clarity

Analyzing the current workflow gave insights to how users struggled to complete their goals.

Identification

Identifying roles that hadn’t been discussed prior to the workflow prevented costly rework.

Refinement

Eliminating steps within the information architecture offered users a faster journey.

Synthesize the Findings

Examining our findings with stakeholders provides an opportunity to redetermine business motivation vs. user goals.

Organizing the Direction

What Do They Want?

The users wanted an interface that would fill their displays and not require any scrolling outside of the viewport for a complete picture.

Why Do They Want It?

For years, the users had relied on a traditional thick-client that tossed best practices aside in favor of densely displayed sets of data.

How Will We Do it?

The new UI would leverage responsive design and be rooted in the MAYA Principal in order to facilitate both requirements.

Prioritize the Findings

Prioritizing features based on impact vs. cost/time further aligns the project and business teams for the project’s success.

Key Features to Design For

User Work Lists

Stakeholders referenced user “queues” in our meetings, but hadn’t considered visualizing them as searchable work lists for users.

Rationale Builder

Each audit required users to write a letter to justify their findings. We crafted a method of searching & using prior texts to lessen the task.

Consistent Design Patterns

Each selected feature would adhere to an established pattern. This allowed consistency in the design throughout the enterprise.

Conceptualize the Design

We create rudimentary designs from the workflows and user journeys in order to understand what actions will be available on a screen-by-screen level.

Conceiving the Interface

Visualize

We relied on art and science to pack the UI with dozens of points of data while creating an incredibly intuitive interface.

Iterate

We explored many layouts, using a fail-fast approach with stakeholders to quickly land on a best-of-breed approach to the solution.

Converge

The stakeholders’ limited bandwidth established an environment for quick rejection and approval of ideas and concepts.

Formalize the Design

Adding a layer of polish by selecting the proper colors and shapes within the interface further enables the users to easily navigate the product to achieve their goals.

Solidifying the Look & Feel

Setting the Foundation

Selecting a core design language to build from afforded us with a shorter development cycle and easier adoption.

Adding Customization

We utilized our observations to shape each function and component of the system to create a beautiful custom solution.

Visual Formalization

A consistent Design System led to a highly scalable and maintainable solution that didn’t require user training to achieve their goals.

Evaluate the Design

By utilizing high-fidelity mockups within clickable prototypes, we begin to validate and refine what will become the final product.

Fail Fast to Gain Success

Identify Blockers

During our usability testing, we were able to uncover areas where the users were lost or unable to complete their tasks.

Encourage Feedback

By quickly updating the prototype with user feedback, we created a collaborative environment where users felt empowered.

Invoking Delight

Testing the final prototype yielded the results we were after, users achieved their goals and were delighted by the experience.

Evaluating the Results

Pre-Engagement Heuristic

Post-Engagement Heuristic

Prototyping & User Testing

With a steady eye on an overall enterprise design system, we created a layout for their internal system needs. This system emphasized speed and the ability to scale. To test the layout, we crafted a click-through prototype with Adobe XD that could be immediately tweaked based on feedback and then retested.
‍
Using this tool allowed us to provide users with a link and a loose script to follow. Each user could interact with the prototype at their convenience and offer their thoughts. The updates would be made and pushed to the same URL, thereby permitting the users to see the results of their feedback.
‍
We took the findings from these exercises and cascaded them through other projects at the organization. This fast-tracked the enterprise design system’s internal user interface creation, and ensured on-time delivery of several products at once.

Results

10+

Daily increase in claim volume per nurse

48%

Increase in SDLC sprint velocity

Workflow friction points removed

26%

Increase in DRG Capture/hit rates

* End metrics are considered ballpark/soft estimates being derived from baseline comparisons and computational averages.