HCL TECHNOLOGIES
Business Experience Designer (XD India)
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.
The Challenges or Problem
We're scheduling a Decision Point Review to improve accuracy and streamline processes. This included a Medical Director Review, Independent Medical Examination, and Pre-Certification. Also, implementing Phase 1 of the FAMES project to enhance efficiency. Converting paper documents to electronic ones while maintaining the same labels and fields to minimise disruption and save time and resources.
Notification Regarding Claims: Assumptions
• Mitchell is responsible for verifying coverage for claims.
• To notify FMCO of a claim, Mitchell must provide the Claim Eligibility File in electronic format as Claim Notification.
Goals & Needs
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To make things easier to use, clearly, label fields, use buttons for actions, and links for information.
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Provide drop-down lists for options and use hot keys for commonly used buttons. Allow for cancelling and closing the browser using the "X" button.
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Apply formatting standards for important information and use visual differences to distinguish between different environments.
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Minimise fields, and group-related info, use inline validation, input masks, and auto-completion.
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Provide feedback, differentiate actions, match text fields to expected input, and avoid placeholder text for a better user experience.
Our Approch
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Improve user experience by prioritising their needs,
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Using clear labelling, organising information logically,
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Providing immediate feedback, simplifying input, using consistent formatting, differentiating actions, matching text fields to expected input, and avoiding placeholder text.
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Regular user testing and feedback collection are important for refining design decisions.
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
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Review and assess treatment plans for medical necessity and adherence to guideline
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Collaborate with other stakeholders, such as attending physicians and utilization review nurses, to gather additional information
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Streamline and improve the efficiency of the Decision Point Review process
Challenges
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Managing a high volume of review cases within a strict timeline
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Staying up-to-date with evolving medical guidelines and regulation
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Balancing the need for accurate decision-making with efficient workflow processes.
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
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Conduct thorough reviews of medical records to determine the medical necessity and appropriateness of services
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Communicate and collaborate with attending physicians and other healthcare providers to gather relevant information
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Support the implementation of the FAMES project and the transition from paper documents to electronic records.
Challenges
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Handling a large volume of cases while maintaining attention to detail
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Adapting to new technology and systems during the transition to electronic records
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Ensuring effective communication with various stakeholders involved in the Decision Point Review process.
Information Architecture & Mind Mapping
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/
Business Impact
Our business goals are to improve accuracy, efficiency, and compliance while reducing costs through automation, streamlining processes, integrating systems, and transitioning to electronic documentation. Our primary objective is to optimise PIP Case Management for greater efficiency and compliance with state regulations.
Validation
We follow a well-defined process that involves creating a comprehensive user experience (UX) and presenting a prototype to our clients. After the prototype is presented and sent the prototype link on the mail, on the same prototype, we carefully collect and assess their feedback to ensure that their requirements and expectations are met. This feedback is obtained from multiple user groups and usability perspectives, providing us with detailed insights that are crucial in achieving the desired outcomes.
Conclusion
Based on the information provided, it appears that the Decision Point Review, along with the Medical Director Review, Independent Medical Examination, and Pre-Certification, are being implemented to improve accuracy and streamline processes in New Jersey s Auto claims PIP Case Management. The organization is also working on Phase 1 of the FAMES project, which involves converting paper documents to electronic ones while maintaining the same labels and fields for maximum efficiency. These initiatives demonstrate the organization s dedication to improving the accuracy of the Decision Point Review process and optimizing workflow efficiency. They are also leveraging technology to transition from manual paper-based processes to electronic documentation. However, it is important to consider that the conclusion may vary depending on specific objectives, constraints, and requirements of the organization. Further information and analysis are necessary to provide a comprehensive and tailored conclusion.