Abstract Icon - SDLC Case Study


One of the largest health plans in the U.S. needed to address their historic pain points around complex project execution and delivery. One of those projects focused on reducing the number of member claims that are rejected due to a lack of prior authorization. SDLC Partners used a Human-Centered Design technique called ethnographic interviewing to evaluate the desirability of the client-suggested solution. When that solution proved undesirable, the teams’ user research uncovered the real need. It provided a pathway to a solution that employees would use, and that would solve the problem of rejected claims due to prior authorization issues. Using ethnographic interviewing, our team saved this client the cost of developing the wrong solution, as well as creating a solution that is projected to deliver 6.5x return on investment equal to four million dollars every year.

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The Challenge

Claims processing accuracy and timeliness is at the heart of what every health plan must do well. Our payer client was struggling to reduce the number of claims that were being rejected due to a lack of prior authorization.

Prior authorization is a requirement from the health plan that a doctor obtains approval from the member’s plan before it will cover the costs of a specific medicine, medical device, or procedure.

Our client found that members had their claims denied, not because the plan was rejecting prior authorizations, but because the providers were not requesting the required prior approval. The untoward effect was that the insurance plan didn’t have the opportunity to evaluate the necessity of the procedure beforehand, and the claims were rejected.

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The Solution

The client proposed adding an easily accessible link in the provider user interface to an existing document that shows which procedures require prior authorization. The client assumed that providers didn’t know where to find the document.

Through our ethnographic interviewing process, however, we discovered that the underlying issue was not that providers didn’t know where to find the document. Our design team found that the users didn’t review the document at all because they didn’t trust the contents of the document. Some providers tried submitting a prior authorization for every procedure, whether it was required or not. Some prior authorizations were rejected as not necessary, but the corresponding claim was denied for not having a prior authorization, indicating a significant data issue within the platform.

Without the use of our ethnographic interviews, we wouldn’t have discovered that the first solution was inappropriate. Our team designed several alternatives, presented as user flows and mockups, that we tested with the end-users to determine the most desirable solution.

The final solution included three parts:

  1. Overcome the data issues within the platform, regaining users’ trust of the information provided
  2. Build the request for prior authorizations into the standard providers’ workflow within the existing application
  3. If a prior authorization is not required, give the provider a receipt with a unique number so that they trust the system and have some way to track that decision, if necessary
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The Results

The initial funding was repurposed to create a desirable solution that promises a 6.5x return on investment every year. Additionally, the client saved months and budget on a solution that would have never been used due to the information we gathered during our ethnographic interviews. Lastly, the underlying issue of trust and confusion around required prior authorizations has been resolved, increasing providers’, employees’, and members’ satisfaction.

“This effort is currently in delivery and, once completed, will feature net-significant efficiencies, anticipated savings in the millions, and much happier users!”

C-Level Executive at Health Plan

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