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Empowering Patients to Navigate Surprise Medical Bills

The Centers for Medicare & Medicaid Services (CMS) partnered with Coforma to implement new Medical Bill Rights legislation that protects patients from surprise medical bills.

The Challenge: Improve Website Accessibility and Systems Interoperability

Client Name:
Centers for Medicare & Medicaid Services
Partner Name(s):
Aquia; U.S. Digital Service; Ad Hoc; Digital Service at CMS
Delivery Date:
June 2023

The Centers for Medicare & Medicaid Services (CMS) wanted to improve the public’s customer experience with their website and enable people to understand and act on their new No Surprises Act protections.

US healthcare system patients have historically faced unexpected bills after receiving care or treatment from out-of-network providers in situations beyond their control. In what’s known as “surprise billing” or “balance billing,” healthcare providers and facilities don’t disclose known, out-of-pocket costs with patients ahead of urgent care or a scheduled visit or procedure and instead send them follow-up bills for the remainder of what hasn’t been paid by their insurance company or otherwise. Surprise medical bills can happen to patients with or without insurance. The average costs of these bills ranged from $750 to $2,600 per event.

Fortunately, the No Surprises Act, passed in 2020 and implemented in 2022, established patient protections, creating the opportunity to address medical bill affordability challenges and change the patient experience to bring about the end of surprise medical bills.

To satisfy the Act’s requirements, CMS needed to quickly update its systems to receive, store, process, adjudicate, and present information related to cases, complaints, costs, and more. To help CMS achieve the complex requirements, Team Coforma applied human-centered design (HCD) research methodologies, evaluative research techniques, content design and plain language best practices, bilingual translation, product and systems design, usability testing, and cross-functional development to bridge user needs with the legislation’s unique requirements. The result was, a mobile-first, bilingual site that presents the public with digestible information and a “Find an action plan” tool–all with integrated forms and a scalable, maintainable back end that CMS could readily update in the future.

It’s organized and professional, but it’s still comfortable. It doesn’t look like it’s all business. It’s just gentle enough to be relatable without being patronizing. . . . Your site is like the digital version of bedside manner.
Test Participant

Our Approach: Evaluative Research Followed by Iterative Development and Testing

We worked collaboratively and iteratively to align the needs and challenges of different patients and caregivers to construct an accessible and usable site without compromising on scalability and manageability.

To build the new site, we engaged CMS stakeholders and patients, caregivers, and patient advocates in user research activities and real-time usability testing so we could learn about their real-life challenges and needs in understanding their rights and options under the No Surprises Act. We synthesized the quantitative and qualitative research data into insights. Then, we created journey maps and design principles to guide our team in crucial decision-making moments and strategies as the work progressed.

To iteratively improve the website's design and its internal infrastructure, our design, engineering, and product experts collaborated to understand the technical challenges and incorporate research insights within these issues. From iterating on original structures to testing designs alongside engineering, testing with patient advocates was crucial in identifying further improvements and recommendations. This approach effectively reduced and eliminated changes mid-sprint for our agile team, improving collaboration and a seamless product handoff to CMS stakeholders.

Next, we enhanced the design and development of the internal infrastructure of the website by providing iterative enhancements and incremental improvements to operations workflows with recommendations for additional opportunities and feature developments. Our recommendations included crafting patient web forms integrated with existing CMS systems and workflows and updating their communication templates. The team also expanded the site’s system functionality to support complaint submission workflow changes and allow for timely updates. With customized support to complement the CMS team’s capabilities and robust documentation of our findings and recommendations, in the future, CMS can scale, maintain, and update the system independently.

Results: Improved Customer Experience on a Modernized Site

The US healthcare system is already difficult to navigate, so we aimed to minimize patient complexity. The site design prioritizes customer service with straightforward information to help people understand their new rights and accessible pathways to apply No Surprises Act protections. We built the site to empower patients and support CMS team additions and changes to future site iterations.

A screenshot of the health insurance question page from

The use of plain language in design focuses on making the content and interface accessible to people of all literacy levels.

Plain Language

Healthcare terminology and legislative jargon are not part of everyday speech. They can make understanding and applying one’s rights difficult, time-consuming, and inaccessible. Our research uncovered plain language equivalents and alternatives to give patients an apparent experience of their new legal rights and their options for complaint submissions, navigating their rights, and resolutions in English and Spanish.

An animated screenshot showing the transition between the English and Spanish-translated home page on

Designing a website with bilingual content acknowledges the diversity of the people using it and provides an inclusive experience.

Bilingual at Launch

We crafted translated content in international Spanish to support understanding across the range of Spanish-speaking regional variations and dialects. We reduced the government cost and time-to-launch over the alternative of localizing content for more than 30 countries with native Spanish speakers. In addition, we used a semantic translation standard, which considers the context, intent, and meaning as part of its holistic translation. We fostered a collaborative, human-centric design after testing the content for clarity with Spanish-speaking users and incorporating their feedback.

A screenshot of the guides and resources page from with various how-to’s and options for assistance.

Prioritizing the needs and expectations of people using the website will ensure they have a seamless and enjoyable experience.

Intuitive, Intentional Design

To empower and inform users, we wanted to ensure the design and visuals for the final products were straightforward and accessible. Our HCD research insights guided the design of the site and the implementation of features that addressed where people were experiencing frustration or confusion. We also utilized the CMS design system to seamlessly integrate the new content into the existing site while reducing customizations so the site would be consistent and easy to maintain and improve post-launch.

A collection of custom illustrations—a person using a laptop, in a wheelchair and completing calculations, solving a puzzle, signing a form, and a family holding hands—used across

Custom illustrations are visually appealing, and inclusive, and make digital content more accessible and welcoming for people of diverse backgrounds and with various needs.

An Inclusive Experience

Keeping in mind the diverse array of people using the site, we created custom illustrations, knowing it was important for people from all backgrounds to see themselves in the characters and scenarios. These illustrations also helped visualize abstract concepts like protection and wayfinding. These illustrations and research insights guided a co-designed website, a conversational Q&A application, and new online forms to empower all individuals to learn more about unexpected medical bills and how to navigate them.

Two side-by-side screenshots of pages in the mobile version of One shows the start of understanding medical billing rights and the other some options for a person’s next steps.

Expanding the functionality of a website ensures a richer and more dynamic experience for the people who use it.

System Integration and Expanded Site Functionality

It was essential to build a site that empowers patients, CMS teams, and other agencies but still meets the required government functionalities. CMS’ new site,, integrates with its existing workflows and processes, has expanded functionalities that reflect its public-facing goals, and establishes a baseline site and system that can be scaled and maintained by CMS.

Project Team

  • SilkeSilke DannemannProject Manager
  • SydneySydney MandapProduct Manager
  • JessJess JonesDesign Lead
  • KateKate MurphyProduct Designer
  • ArdenArden KlemmerProduct Designer
  • RosemaryRosemary RogersResearcher
  • SabrinaSabrina FonsecaResearcher
  • JamieJamie Klenetsky FayContent Designer
  • CeciliaCecilia RamirezContent Designer (Spanish)
  • CoformaCoforma StaffTechnical Lead
  • TannerTanner HeffnerTechnical Lead
  • JasonJason PoteetSoftware Engineer
  • SophieSophie KwakSoftware Engineer
  • LixhjidenyLixhjideny Méndez RíosSoftware Engineer
  • JessJess EldredgeSoftware Engineer


  • Acquia Cloud and ACLI for hosting Drupal and automation

  • Akamai for access control to Acquia environments using ACA tokens, caching to handle load, performance alerting, and DNS

  • Box and Google Drive for documentation, file delivery, communication, and collaboration

  • Cloudbees Jenkins for continuous integration and deployment

  • CMS Design System for system design

  • Composer for Drupal dependency management

  • Confluence for documentation and file delivery

  • Cypress for framework testing

  • DDEV and Drush for automation in Drupal development

  • Docket for development environment

  • Drupal for a content management system and version control

  • ESLint to identify code errors

  • Figma for design and illustrations

  • GitHub Enterprise for source control

  • Google Analytics for digital analytics program

  • Google Workspace for client reports

  • HTML/CSS/JavaScript for web technology stack

  • Jira for planning, task management, and sprints

  • Mural for collaboration, processes, roadmap, and retrospectives

  • Qualtrics for survey and feedback form distribution

  • Questionable via USDS for question flow structuring

  • React for enhanced UX and improving maintenance development experience

  • RESTful API integrated with Salesforce API and to expose AI for user interface

  • Salesforce for integration with the custom API

  • Slack and email for communication and collaboration

  • SonarQube for automated security testing

  • Zoom for communication and collaboration


  • Human-centered design research methodologies

  • Scrum framework for Agile delivery

  • SEO audit and site search analysis

  • Usability and content testing

  • End user testing

  • Scalable product design

  • Content design

  • Illustration

  • Rapid iteration

  • Inclusive design

  • Accessibility audit

  • Plain language and Spanish translation