Much of the heavy lifting in creating a claims status tool is the upfront work of process mapping. For example, one state conducted weekly meetings with 25 staff members from different parts of the agency to map out the claims statuses currently shown in their claims status tool. However, it took several months of meetings to map out the various statuses that added value to their claimants’ experience. Once they had this on paper and understood exactly what data was available, the implementation was straightforward.
There is also a long-term benefit to this documentation work: bringing everyone together through this exercise can clarify ambiguous procedures and uncover operational improvement opportunities.
When considering how to implement or improve upon a claims status tool, it’s important to have a thorough understanding of your state’s UI processes, systems, and tools. Once you have a complete picture of the process and the various touch points between claimants and state agency staff, you can identify the information that should be available to both claimants and staff.
Recommendations
Here are a few ways that you can evaluate your processes.
One helpful artifact to start with is a user journey map. This will help you to put on the claimant’s shoes and give a high-level picture of how they experience the process. It will also serve as the foundation for how to represent a high-level status to claimants in a tracker-like tool.
The user journey map should encompass the expected steps in the claims process that apply to all claims, including determinations, waiting weeks, employer response time periods, how long claimants have to certify, and so on. We don’t recommend documenting granular processes with issue resolution or adjudication at this step since those can get quite complex. Read the next section, ‘Document issues’, for additional detail on how to account for those details.
When building a journey map, highlight the following process elements:
- What happens when someone is denied? What should they do?
- What happens when a claim is pending adjudication or fraud review for an excessive time period? What recourse do claimants have?
- How long do various steps take? For example, are claims commonly delayed because claimants do not respond in a timely way?
This section aims to bring together the operational and technology experts on your team to identify the issues and next steps that impact the claimant experience.
A journey map will help you understand the claimant experience and identify current barriers and areas in which communications could be improved. These barriers are commonly referred to as “issues.” This term can have slightly different meanings in different states. But for our purposes, an “issue” is anything that prevents or delays payments from going out – adjudications, fraud investigations, and so on.
Depending on the state of your documentation, this will likely be the project's most challenging and time-consuming part. In one example of this type of project, getting a partial list of issues took six months and involved more than 20 stakeholders. However, this step is the most critical for the success of the project. Without an internal understanding of the breadth and logic behind the possible issues in the process, it’s impossible to communicate the information to claimants.
This exercise should include the following:
- List all the possible issues that can delay a claim.
- List all the action items that claimants could be required to take in the lifecycle of a claim, such as providing documents, scheduling appointments, and completing weekly certifications.
- Identify what data is available in your system and how you would programmatically know if there is an issue or if the claimant needs to take action.
- Document the current level of visibility into each issue. What information do claimants currently have access to when a particular issue happens? Do claimants get alerted? What information does the contact center staff have access to in those cases?
- Define which data is available to you to understand how frequently each issue occurs and how long it takes to resolve it. This information will help you prioritize the next steps to improve your claimants' experience.
Checklist
- You have documentation about the different paths a claim can take and the issues that delay payments.
- You can identify specific pain points to target and prioritize for your claims status tracker.
- You have a list of statuses you can recommend for your state to prioritize.
Key questions
- What are the claim details currently shown to claimants?
- Which areas do claimants struggle to act on more often?
- Which issues are the most common?
- Which issues take the most time to resolve and create the biggest burden on claimants?
- Are there statistically significant differences in claimant success rates or the number or type of issues experienced by claimants based on race, ethnicity, sex, age, disability status, or other demographic categories?
Interested in addressing claims status? Email the UI Modernization Team
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