Redesigning the Medical Claims Experience: Enabling Clarity, Confidence, and Control for Members
This research-led initiative aimed to reimagine how health plan members engage with their medical claims through a mobile experience. We conducted qualitative research to understand users’ priorities, pain points, and mental models around claims and Explanation of Benefits (EOBs). By mapping the member journey and facilitating ideation sessions with stakeholders, we identified critical friction points and opportunities for improvement across the claims lifecycle.
Key goals included uncovering gaps between current and ideal experiences, identifying key moments in the medical journey that intersect with claims, and exploring barriers to comprehension and engagement.
Research Objectives
Explore user needs and priorities in accessing claims information.
Assess current user experiences and interactions to identify gaps in comparison to their ideal claims experience.
Identify key stages in the user's medical journey that impact the claims process, aiming to uncover gaps and potential enhancements.
Investigate perceived barriers hindering user engagement and comprehension of claims and Explanation of Benefits (EOB) statements.
Timeline
3 Months
Research Activities
Project Scoping, Recruitment, User Interviews, Member Journey Map, In-Person Ideation Workshop, Prioritization and Roadmapping
Team
Lead Researcher
Support Researcher
UX Designer
Project Manager
Director, Experience Design & Delivery
Immersion
Immerse and understand the industry by familiarizing with products, terminology, and challenges. I approached this by conducting stakeholder interview, building user flows, having website walk-throughs to create an assumptive member journey map.
Methodology and Recruitment
To uncover member’s claims journey and evaluate the current experience, facilitating generative + evaluative research approach for a more structured study.
Participants were recruited using a digital platform based on criteria:
Must have had interactions with their insurance company’s app or website regarding claims within the past 6 months
Must have checked claims status, reviewed claims information and cost breakdown, and sought support from insurance company in the past 6 months
User Interviews - 90 minute | 1:1 session | 24 participants
Key Insights
Improve status communication to help members feel confident and supported
Help members leverage detailed cost information to find errors and plan efficiently
Surface information that matters to find the right claim
Explain coverage results to members can understand issues and assess plan success
Help members effortlessly track plan usage to make most of their plan
Offer members different levels of support for unexpected next steps
Ideation Session
An ideation session with stakeholders helped encourage creative thinking and generation of new ideas to solve existing pain points using HMW statements.
In a 4-hour cross-collaborative workshop, we generated range of ideas using journey map and research insights, which were translated into HMW statements.
Ideation activities included:
•Brain Writing: Goal was to create as many ideas as possible
•Idea Refinement: Share ideas in group and combine the best of each into a concept.
•Concept Poster: Create a pitch for the concepts and share with the team
•Voting for the best concept or parts of the concepts.
Prioritization
All concepts are prioritized in an engaging workshop on different scales:
Value to users
Business/ Product roadmap Alignment
Tech Feasibility
Key Takeaways
Aha Moments
Even when a claim appears unjustified to users, the complexity of the appeal process often leads members to pay the disputed amount instead of contesting it.
Some users still prefer using paper methods for making payments rather than adopting technology.
The lack of transparency in the claims process creates significant anxiety among members, with some waiting over a year to receive their claims.
Positives
Regular weekly check-ins and an engaging approach ensured team buy-in and active participation.
Collaboration with UX Designers ensured that research insights and recommendations were actionable and relevant.
Challenges
Misalignment within the team about the need to recruit more current users of Medical Mutual
Teams need constant education about each phase of the research process to ensure everyone understands the objectives and methodologies