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Johns Hopkins Medicine Office of Managed Care

SAI was tasked with helping the Office of Managed Care reduce time to revenue and decrease processing time and effort. Find out what our solution entailed.

Navigating the Managed Care Landscape

The Office of Managed Care (OMC) plays a pivotal role in ensuring that the ten hospitals and over forty affiliated clinical care facilities across Johns Hopkins Medicine (JHM) receive payment from insurers (third-party payors) for healthcare services provided; payments that account for over $5 billion in annual revenue. One of the OMC’s key responsibilities is providing relevant payor and regulatory education, and health plan information to billing specialists across all JHM entities.

These billing specialists verify that patients’ procedures are covered by their respective health insurance plan, bill health insurance providers for medical services provided, and ensure that all applicable laws and regulations are followed in the process. The OMC provides the information, resources and support billing staff need to make the accurate processing of medical claims possible.

Providing hundreds of billing specialists across Johns Hopkins with timely and accurate information on the 50+ health insurance plans accepted by Johns Hopkins as well as on the evolving landscape of health insurance regulations was a struggle. Insurance providers regularly changed rules around procedures covered and verification/approval requirements, making it very difficult for billing staff to keep up with current rules and requirements. These issues had significant revenue implications if Johns Hopkins performed services that an insurance provider would not cover. 

A legacy intranet platform existed that provided documentation on each health insurance provider, their rules, and verification and billing procedures. But this intranet was just a collection of PDF documents from insurance providers, each in a different format, some out of date, and all difficult to search, use and manage. SAI Digital set about to solve the problem by developing an easy-to-use web-based application to manage and distribute detailed health insurance payor information.

JHM OMC responsive design on 3 devices

Creating an Intuitive Experience

SAI Digital team members launched the project with interviews and focus groups with a broad cross-section of JHM staff involved in the process, from leadership to training staff to billing specialists, all with the goal of quickly developing an in-depth understanding of the managed care verification and billing process. The team then progressed to developing process flows and interactive prototypes to test various approaches and user experience options, using an Agile process to design the user interface, iteratively reviewing with the OMC team and adjusting accordingly. Broad involvement from the OMC team ensured that the approach was on target and also made the training process easier since many OMC staff had an opportunity to review and provide input on prototypes throughout the process.

Managing Change

This project also entailed a structured change management effort which introduced the new platform and refined processes to JHM billing staff. To ensure buy-in, JHM staff were involved throughout the prototype process, in QA once the application was complete, and participated in a “road-show” to demo the application and key benefits. The result was a smooth roll-out and enthusiastic adoption allowing JHM team members to perform their work more efficiently and accurately and optimize the collection of revenue from third party payers.

mobile screens
Screen captures

Key Capabilities

The application provides a wealth of information about each health insurance plan accepted including eligibility and billing information, notices, images of sample insurance cards and exclusions. It also provides a powerful search and multiple pathways to information allowing billing staff to compare requirements around specific procedures across healthcare providers and approved services/providers at various Johns Hopkins Medicine hospitals and service locations. The fully responsive mobile-optimized layout enables access across all devices and a set of APIs provides the ability to feed data to other websites and platforms via web services.

The Results

Deployment of the new platform has enabled hundreds of JHM billing staff to more efficiently and more accurately verify/approve and bill for healthcare services, supporting JHM’s broader objective of reducing time to revenue and decreasing processing time and effort. A few months after launch, usage of the application saw a significant increase over the tool it replaced. More importantly, we continue to monitor efficacy, where data now shows sustained growth in usage at an increase four times greater than its predecessor platform.