FMCO Case Study
First MCO Auto Management Enterprise System

The First MCO (FMCO), the business workflow, was established and implemented in phases. This involves utilising the current system and the new functionality listed below to fulfil the proposed workflow. PIP Case Management of New Jersey s Auto claims includes Decision Point Review, Pre-Certification, and Utilisation Review. These processes are initiated by three state forms Attending Physician Treatment Plan, Pre-Service Appeal, and Post-Service Appeal. First MCO's business processes for Decision Point Review, which includes Medical Director Review, Independent Medical Examination, and Pre-Certification, along with implementing the First MCO Auto Management Enterprise System (FAMES) project Phase 1, was to ensure efficiency and accuracy.

How User Research, Design Thinking & Iteration Solved a Complex Auto-Claims Workflow

1. The Situation:

When Paper Slowed Down Critical Decisions. At First MCO (FMCO), Decision Point Review was the heart of New Jersey’s Auto PIP claims process.

Every claim passed through:

Medical Director Review
Independent Medical Examination (IME)
Pre-Certification
Utilization Review

But the system behind it was fragile.

Most work still depended on:

Paper forms
Manual tracking
Faxed or scanned documents
Multiple handoffs between teams

Every delay meant:

Slower claim decisions
Higher operational cost
Risk of non-compliance
Frustrated doctors and nurses

The business asked one simple but dangerous question:

“Can we move to digital without breaking what already works?

”Thus began Phase 1 of FAMES — the First MCO Auto Management Enterprise System.

2. The Design Challenge

The problem wasn’t just “make a new system.

”The real constraints were:

Existing paper forms had to stay visually familiar
Labels and fields could not change drastically
Users were not tech-savvy
Volume was high, timelines were strict
Errors had legal consequences

So the design goal became:

Digitise without disrupting.
Improve without overwhelming.
Automate without losing trust.

Screenshot 2023-06-21 at 11.52.13 AM.png

3. Starting with People, Not Screens

Begin with User Research-

We began by meeting the real heroes of the system:

Medical Directors
Review Nurses
Case Managers
Admin Staff

We observed them:

Filling paper forms
Searching for missing pages
Calling physicians for clarifications
Rewriting the same data again and again

We conducted:

Contextual interviews
Shadowing sessions
Process mapping workshops

What We Discovered

Speed mattered more than beauty
Errors usually happen during re-entry
Users relied on memory, not system help
People feared “new systems”
Familiar layout = confidence

One nurse said:

“If the screen looks like the paper I know, I’ll trust it. If it looks new, I’ll be scared to click.

”That single sentence shaped the entire design.

4. Defining the Real Problem

Using Design Thinking, we reframed the challenge:

Not:
“Build a digital claims system.”

But:

“How might we help medical and review teams make faster, safer decisions without changing the way they think?”

Personas

Dr. Michael Ramirez

Medical Director

Age: 37

Dr. Ramirez is an experienced medical director with expertise in reviewing and approving treatment plans for auto claims. He has a deep understanding of medical guidelines, regulations, and the decision-making process involved in the Decision Point Review. Dr. Ramirez plays a crucial role in ensuring the accuracy and compliance of the review processã

Goal

Review and assess treatment plans for medical necessity and adherence to guideline
Collaborate with other stakeholders, such as attending physicians and utilization review nurses, to gather additional information
Streamline and improve the efficiency of the Decision Point Review process

Challenges

Needs

Managing a high volume of review cases within a strict timeline
Staying up-to-date with evolving medical guidelines and regulation
Balancing the need for accurate decision-making with efficient workflow processes.

Needs fast access to case details
Reviews dozens of cases daily
Hates scrolling and hunting
Wants accuracy without delay

Rachel Anderson

Review Nurse

Age: 32

Rachel is a dedicated utilization review nurse responsible for reviewing and monitoring the utilization of medical services for auto claims. She has a strong knowledge of medical procedures, healthcare protocols, and insurance guidelines. Rachel s expertise ensures the appropriate and cost-effective use of medical resourcesã

Goal

Conduct thorough reviews of medical records to determine the medical necessity and appropriateness of services
Communicate and collaborate with attending physicians and other healthcare providers to gather relevant information
Support the implementation of the FAMES project and the transition from paper documents to electronic records.

Challenges

Handling a large volume of cases while maintaining attention to detail
Adapting to new technology and systems during the transition to electronic records
Ensuring effective communication with various stakeholders involved in the Decision Point Review process.

Needs

Handles high volume
Manages transitions from paper
Needs clarity, not complexity
Wants guidance from the system

Every screen asked one question:

“Would Dr Michael find this fast?”

“Would Rachel feel safe using this?”

6. From Chaos to Structure: Information Architecture & Mind Mapping

Screenshot 2023-06-21 at 12.41.14 PM.png

We mapped:

Every form
Every decision step
Every handoff

Then created:

Mind maps
Task flows
Decision trees

We grouped:

Claim info
Patient info
Provider info
Review actions
Compliance steps

Nothing was added unless it supported a real task.

7. Designing with Familiarity First

Key UX Principles

Same labels as paper forms
Same sequence as paper flow
Fewer fields, smarter grouping
Inline validation
Auto-completion
Input masks
Clear buttons for actions
Links for information
Hotkeys for frequent actions
“X” to close, always respected

We avoided:

Fancy placeholders
Hidden actions
Overloaded screens

The system spoke the users’ language — not the designers’.

8. Iteration: Design, Test, Fix, Repeat

Round 1:

Low-Fidelity Wireframes

We tested:

Navigation flow
Field placement

Screen orderFeedback:

“Too many fields on one screen”
“I can’t see what’s mandatory”
“I miss my old section order”

We changed.

Screenshot 2023-06-21 at 11.51.33 AM.png

Round 2:

High-Fidelity Prototype

We added:

Visual hierarchy
Formatting for critical info
Error messages

Environment colour differences (Test vs Live).

Tested with:

Doctors
Nurses

Admin usersFeedback:

Faster than paper
Less re-entry
Fewer mistakes
Less calling back doctors

One nurse said:

“I don’t think anymore. I just follow the screen.”

That was a success.

Screenshot 2023-06-21 at 11.51.56 AM.png

Wireframe/Designs

https://xd.adobe.com/view/5fc3b160-4399-48a4-8264-cc1931341437-0a90/

ttps://xd.adobe.com/view/a4a58cf3-8048-4ee2-8a42-e44fe5c21386-f1f6/?fullscreen

https://xd.adobe.com/view/5fc3b160-4399-48a4-8264-cc1931341437-0a90/

9. From Paper to Digital — Without Breaking Trust

The biggest win:

Same labels
Same logic
Same flow
But now:

Automation quietly removed friction while keeping familiarity.

No lost papers
No double entry
No unclear handwriting
No manual tracking

10. Business Impact

FAMES Phase 1 delivered:

Faster Decision Point Reviews
Higher accuracy
Better compliance
Lower operational cost
Reduced manual work
Faster training for new staff

Business goal achieved:

Efficient, compliant, and scalable PIP Case Management.

11. Validation & Continuous Learning

After launch:

Prototype shared via email
Feedback collected on same prototype
Multiple user groups involved
Changes made based on real use

Design didn’t stop at launch.
It evolved with users.

12. Conclusion & Final Reflection

This was not just a “design project.”
It was a trust-building project.

We didn’t force users to change.
We changed the system to respect them.

By combining:

User Research
Design Thinking
Iteration
Validation

We turned a risky digital transformation into a safe, trusted, and successful system.

FAMES Phase 1 proved that good design doesn’t shout.
It quietly makes hard work feel easy.

FMCO Case Study First MCO Auto Management Enterprise System