Transforming Pre-Authorization
2018
Challenge
Cambia Health Solutions, holding company for Regence Blue Cross Blue Shield health insurance, was seeking radical new solutions to Pre-Authorization, the existing mechanism health insurers use to determine whether treatment is medically necessary and therefore will be covered by insurance. According to a 2018 American Medical Association survey, 1 in 4 doctors say that Pre-Authorization has led to a serious adverse health event. Specifically, our initial problem statement was, “How might we maintain the value that Pre-Authorization creates [value for the insurer] without requiring the member to experience Pre-Authorization?”
Experience Design Lead, responsible for scoping the engagement and leading a cross-functional team of 8 through discovery, synthesis, concept, and prototyping.
My Role & Approach
The highly cross-functional team was comprised of representatives from network management, medical policy, pharmacy PA, provider data, health plan ops, program management, and executive sponsorship. The approach was rooted in co-creation and human-centered design methods to deeply understand consumer and provider needs before designing solutions.
- 4+-hour facilitated workshops per week for 4 months
- 36 in-depth in-person interviews, 16 consumers, 20 providers and staff
- 50+ concept ideas generated and evaluated for Horizon Three characteristics
- 6 prototypes for testing
- 33 in-person field tests, 17 consumers, 16 providers and staff
- 4 modular solution components
- 20 internal feasibility assessment interviews
- 1 Final recommendations report
ARTIFACTS
Results
CEO approval for funding and pilot testing
Partnering with a hospital system to integrate into EMRs Fall 2019
Graphic Design by Roel Uleners