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The Problem

More often than not, medical bills are a source of confusion for patients and families. There is currently no standard for consumer medical billing documents: bills vary in content, presentation, and use of health industry jargon. Consumers also receive bills and explanations of benefits from multiple sources for the same episode of care long after the encounter. It can be difficult to understand what expenses the insurance plan covers and what amounts consumers are responsible for paying, and it can be difficult to verify whether the bills are correct or complete. This can result in anxiety or frustration, and can lead to problematic outcomes, such as hesitancy to seek care, non-payment, under-payment, or over-payment of medical expenses.

Patients often interact with many different people and organizations when they seek care, from their primary care physician, to the hospital where they may see a specialist or have a procedure, the lab where they may have a test done, the pharmacy where they get their medication, and their insurance company. They will also seek out information, recommendations, and resources on the Internet and from friends and family. The business relationships, data flow, and technology infrastructure of each of those organizations impacts the patient experience. Most of the entities involved have a relationship with the patient, but do not necessarily coordinate behind the scenes within their organization or with other organizations involved when it comes to the billing process. Many voices end up communicating with the patient, rather than one, cohesive voice. This leads to patients having to piece things together on their own and undermines patient satisfaction with both providers and payers. 

Examples of the things a patient may see as they interact with various organizations throughout the process:

The dual purpose of this challenge is to redesign the medical bill itself so that it is easier for patients to understand, as well as to innovate the experience of medical billing to make the financial aspect of health easier to manage.

  


Research Insights

Challenge participants are encouraged to review the research and insights below and consider it in their response to the challenge.  Challenge participants are also encouraged to leverage a human-centered design process in the creation of their concept and to follow plain language guidelines. More information on these topics is provided below.

In addition to a survey with 300+ patients and families, Mad*Pow conducted one on one interviews with 25+ patients, families, and representatives from health systems, insurance companies, and integrated systems to uncover core issues and opportunities associated with medical billing and medical cost estimation. 

 


Current State Journey & Ecosystem

  • Example Current State Patient Journey: This journey illustrates one of the many ways a patient may experience medical billing. There are many variations to this core journey. This journey is provided as an illustrative example for participants to get a sense for how the medical billing system operates, and how issues manifest throughout the process. 
  • Ecosystem Map: This Ecosystem Diagram presents the many people, organizations, processes, artifacts, and environments that can be involved in the Medical Billing Ecosystem. The actors that become involved depend on the specific journey that the patient has. Please refer to The Current State Patient Journey for an example journey to see how these elements come together.  Similar people, processes, artifacts and environments are aligned across columns.

 


Additional Resources

Q&A Webinar

"A Bill You Can Understand" Design & Innovation Challenge Webinar Presentation

Click the play button below to view the webinar recording

 

Guidelines, Checklists, and Regulations:

  • Simplify the Medical Bill: A Clear Communication Checklist (Courtesy of the HHS Health Literacy Workgroup and the National Academies of Sciences, Engineering, and Medicine Roundtable on Health Literacy)
    • This three-element Clear Communication Checklist is based on state-of-the-science health literacy, plain language and usability principles.  Designers should use the list to help them meet the Challenge’s criteria for Clear Communication. 
  • Human-Centered Design Process Guideline
  • Medical Bill Information and Data
  • Federal & State Requirements: No federal regulations exist for the format of medical bills. However, IRS 501(r) regulations outline the notification requirements for financial assistance policies on the medical bill. From a state perspective, VermontOhioWisconsin have rules and regulations related to medical bills. This source includes a summary of state requirements regarding when an explanation of benefits (EOB) should be sent to patients (current as of 2012). New York is an example of one state that requires EOBs include specific information.

Relevant Literature & Articles 

     

Relevant Organizations: 

There are many organizations that are active in the medical billing space. These organizations provide services that help consumers estimate the cost of care, view their bills, and pay their bills as well as services that help health organizations provide better tools and services to patients. The organizations listed below are provided as examples to give challenge participants a sense for what is going on in the marketplace. This list is not all-inclusive and challenge participants are encouraged to do their own marketplace research and analysis.

 

 
 
 
 
 
 
"I contacted both the provider and insurer to tell them about an error, which took two months to resolve. I should charge for my time."

- MAD*POW PATIENT SURVEY RESPONDENT

 
 
 
 

61%

of Mad*Pow patient survey respondents rated their medical bills as confusing or very confusing.

 
 
 
 
"I got a statement from my insurance company saying I’d receive another bill, for what I don't know!"

- MAD*POW PATIENT SURVEY RESPONDENT