This is not a bill: Oscar’s journey to create a better EOB | Oscar Rx | hioscar Blog | Oscar
This is not a bill: Oscar’s journey to create a better EOB
Explanations of benefits (EOBs) are confusing. Oscar’s on a mission to simplify them.
Behind the ScenesOur Culture
7 min read
Ashley Taylor Anderson
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A few years ago, Oscar CEO Mario Schlosser had a major WTF moment.
After nine months of doctor’s visits, prenatal vitamins, and preparations, Mario’s wife gave birth to their first child. When they returned home from the hospital, they began to receive a stream of medical documents in their mailbox along with the congratulation cards. Each one was peppered with alarming exclamation points, cryptic codes, and dollar signs.
These documents, known within the healthcare industry as explanations of benefits (EOBs) (opens in new tab), listed a number of standard maternity services his wife received during her pregnancy. Mario knew they weren’t bills—they said so in big letters at the top—but he couldn’t make sense of what these documents meant or what he was supposed to do with them. It was extremely frustrating.
This experience is all too common for many insured Americans. Consumers don’t know what services they’ll receive when they go to the doctor, how much their insurance will cover, and how much they’ll owe. Health insurance companies attempt to communicate this information in EOBs, but they’re often so impossible to read, consumers are left feeling even more confused.
Mario’s struggle to decipher the hieroglyphics of his wife’s EOBs inspired him to start Oscar in 2014. Since then, the team has been obsessed with simplifying the healthcare experience. Here’s how Oscar blazing a new trail for EOBs in the 21st century.
At Oscar, an EOB is more than just a document—it’s a key part of the member experience, and we’re constantly working to improve it. Every iteration of the EOB has involved a team of engineering, product, marketing, and medical operations experts putting their heads together to devise a more streamlined way to communicate key claims information, both on paper and digitally.
Goals
Josh Long, Director of Design on Oscar’s product team, has worked on a few versions of the EOB. Unlike standard EOBs, which rely on cryptic codes and complex keys, Oscar’s goal is to provide clarity to members up front about what they actually owe for their health care.
“The most necessary information is on the front page of the EOB. We want to show exactly what the member needs to know at a glance, and then do a deep dive later,” says Josh.
On the technical side, the main goal is to build a system that can scale and accommodate ongoing iteration. Stephen Kalmakis, Software Engineer at Oscar, says, “We wanted to develop a solution where engineering wouldn’t have to get involved every time a CPT code changes or language needs to be refined. Our product manager is empowered to make those updates on her own.”
The system also needs to support logic for a variety of different claims scenarios such as denied claims, claims with errors, approved claims with various types of benefits applied, and claims with personal health information (PHI) hidden for HIPAA compliance. This logic determines the services information on the EOB and the related explanatory copy.
Challenges
Creating a simple, easy-to-understand EOB takes a lot more mental gymnastics than designing an ordinary document. The team has wrestled with a number of challenges along the way, and continues to overcome obstacles as they refine the product.
One of the main challenges during the first iteration was developing logic and copy to serve multiple insurance plan types. “When we originally started working on the EOB, we only had one kind of plan. Then we introduced Simple plans, and we had to rethink the logic and copy to fit multiple plan types,” says Stephen. Any time new plan types are added, the existing copy and logic has to be reworked to ensure it makes sense for every scenario.
Another ongoing challenge is finding a way to simplify a highly sophisticated set of claims codes and logic into a document consumers can read without getting a headache.
“How do we explain claims information, which is inherently complex, in a way that’s easy to understand and doesn’t take up a ton of space?” says Josh. This is the question the team has been trying to answer with Oscar’s EOB. While simpler is always better, there’s a constant push-pull between brevity and utility. Many common insurance terms used in an EOB aren’t part of the average consumer’s vocabulary, so those terms need to be defined along the way—without adding too much bulk to the copy.
Approach
It may seem strange to treat a print document (and its online counterpart) as a product, but that’s exactly how Oscar approaches its EOB. The cross-functional EOB team works in sprints, starting with Stories and then breaking those Stories into requirements, UX and design tasks, and development tasks. The product manager and product marketing team provide guidance and feedback throughout the process, communicating progress with the rest of the business and, eventually, to members.
“Our process is very similar to a typical product development process,” says Josh. “The differences are mainly in the details. For example, we have more rounds of iteration during the planning and design phases to think through all the permutations and edge cases. We also have a much simpler user flow (first and second touch) to design for than the average digital product.”
After each version of the EOB rolls out, the team captures feedback from members and then uses that data to inform the next iteration.
A quick look at Oscar’s current EOB
The current print Oscar EOB displays high-level information up front: Who gave the care, how much it cost, and how much Oscar covered. It also clarifies how much, if anything, the member might be billed for:
The details of the care received are listed later in the EOB, including price, plan discount, and how much Oscar paid for each service:
A running total of the member’s payments throughout the year is listed at the bottom of the page so they can track how much they’ve spent toward their deductible and out-of-pocket max:
There’s also a unique link in every printed EOB to an online version that provides additional details for each line item:
Uncovering common EOB issues
Before Oscar began working on the upcoming fifth version of its EOB, Athira Nair and Reo Howard, members of Oscar’s Operations team, spearheaded a deep-dive analysis of customer service calls relating to claims and EOBs.
They found that over 25% of member calls were related to EOBs and claims, and uncovered four common pain points:
Members saw a service, doctor, or diagnosis listed on their EOB they didn’t expect to be there.
Members claims were denied, often requiring additional information to be reprocessed.
Members saw a cost-share amount listed on their EOB, but were unclear how that amount was determined.
Members received an EOB for a dependent or spouse on their plan that was scrubbed of detailed information due to HIPAA privacy laws.
Building a better EOB
After gauging member pain points from their analysis, the Ops team partnered with Engineering, Product, and Marketing to sketch out what the next-gen EOB should look like. Athira describes it this way:
In my ideal version of the EOB, a denied or partially denied claim has a very clear and simple explanation of why, what next steps are being taken, who needs to take them, and whose financial responsibility services fall under. That way, it’s clear what action items come out of the EOB and how financial responsibility could change if the claim is updated. Not having that level of clarity at your fingertips—that’s the pain point that frustrates me the most.
Following months of development, the team narrowed down the key features they would hone in on for the next generation of Oscar’s EOB:
Clear ICD-10 and CPT codes that clearly communicate the services rendered, how much they cost, and how much Oscar pays for each line item.
Improved messaging to communicate how claims were processed and why they were denied in clear, consumer-friendly language.
HIPAA authorization messages that prompt the primary account holder to file authorizations for their spouse and dependents 18 years or older.
Multi-language translation services for 28 languages available to Oscar members.
Each of these improvements was carefully weighed against the overarching goal of maintaining clarity and simplicity. The team is keenly aware that adding more information to the EOB, even just a little bit at a time, could quickly lead to an unwieldy end product.
The EOB of the future
While there’s still work to do to make EOBs friendlier, easier to read, and more useful to consumers, the vision is clear. In the future, Mario and his family will scan through their EOBs as easily as scanning a restaurant bill. The frustrations, apprehensions, and confusions stemming from past EOBs will be a distant memory as Oscar and other insurance companies develop smarter, simpler, member-focused EOBs.
