HEALTHCARE DOMAIN

Healthcare Basic Terminologies:

Medicare:

In the United States, Medicare is a national social insurance program, administered by the U.S. federal government since 1966, currently using about 30 private insurance companies across the United States. Medicare provides health insurance for Americans aged 65 and older who have worked and paid into the system. It also provides health insurance to younger people with disabilities, end stage renal disease and amyotrophic lateral sclerosis.

Medicaid:

Medicaid in the United States is a social health care program for families and individuals with low income and limited resources. The Health Insurance Association of America describes Medicaid as a "government insurance program for persons of all ages whose income and resources are insufficient to pay for health care".

Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States. It is a means-tested program that is jointly funded by the state and federal governments and managed by the states, with each state currently having broad leeway to determine who is eligible for its implementation of the program.

Clearing houses:

In medical billing, companies that function as intermediaries who forward claims information from healthcare providers to insurance payers are known as clearinghouses. In what is called claims scrubbing, clearinghouses check the claim for errors and verify that it is compatible with the payer software.

The clearinghouse also checks to make sure that the procedural and diagnosis codes being submitted are valid and that each procedure code is appropriate for the diagnosis code submitted with it. The claim scrubbing edit helps prevent time-consuming processing errors.

Each provider chooses which clearinghouse it wants to use for submitting claims. Most clearinghouse companies charge the providers for each claim submitted, and they also charge an additional fee to send a paper claim to a certain payer.

Clearinghouses may submit claims directly to the payers, or they may have to send a claim through other clearinghouse sites before reaching the payer(s)

Third-party administrator:

A third-party administrator (TPA) is an organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity. This can be viewed as "outsourcing" the administration of the claims processing, since the TPA is performing a task traditionally handled by the company providing the insurance or the company itself. Often, in the case of insurance claims, a TPA handles the claims processing for an employer that self-insures its employees. Thus, the employer is acting as an insurance company and underwrites the risk. The risk of loss remains with the employer, and not with the TPA. An insurance company may also use a TPA to manage its claims processing, provider networks, utilization review, or membership functions. While some third-party administrators may operate as units of insurance companies, they are often independent.

Explanation of Benefits:

An explanation of benefits (commonly referred to as an EOB form) is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf.

The EOB is commonly attached to a check or statement of electronic payment.

An EOB typically describes:

·         the payee, the payer and the patient

·         the service performed—the date of the service, the description and/or insurer's code for the service, the name of the person or place that provided the service, and the name of the patient

·         the doctor's fee, and what the insurer allows—the amount initially claimed by the doctor or hospital, minus any reductions applied by the insurer

·         the amount the patient is responsible for

·         adjustment reasons, adjustment codes

EOB documents are protected health information.

Electronic EOB documents are called edi 835 5010 files.

COB (Coordination of Benefits):

 This is the process by which a health insurance company determines if it should be the primary or secondary payer of medical claims for a patient who has coverage from more than one health insurance policy.

National Drug Code (NDC):

 A system employed by healthcare providers and insurance companies for classifying and identifying drugs. Each prescription drug in common use is assigned an NDC number.

Case Management:

 When a member requires a great deal of medical care, the health insurance company may assign the member to case management. A case manager will work with the patient's healthcare providers to assist in the management of the patient's long-term needs, with appropriate recommendations for care, monitoring and follow-up. A case manager will also help ensure that the member's health insurance benefits are being properly and fully utilized and that non-covered services are avoided when possible.

Health Exchanges:

In the United States, health insurance marketplaces, also called health exchanges, are organizations set up to facilitate the purchase of health insurance in each state in accordance with the Patient Protection and Affordable Care Act (ACA, known colloquially as "Obamacare"). Marketplaces provide a set of government-regulated and standardized health care plans from which individuals may purchase health insurance policies eligible for federal subsidies.

Abbreviation:

AMA CM	American Medical Association Clinical Modification
COB PCF	Coordination Of Benefits Patient Claim Form
DC DDE DRG	Diagnosis Code Direct Data Entry Diagnosis-Related Group
EDI EMR EHR ERA EFT EOB EPS CPT	Electronic Data Interchange Electronic Medical Record Electronic Health Record Electronic Remittance Advice Electronic Fund Transfer Explanation Of Benefits Electronic Payments and Systems Current Procedural Terminology
ICD	International Classification of Diseases
HHS HIPAA HCPCS HMOs HL7 MCOs MITS NPI OCR PPOs POS PBMs PCP PCS	Health and Human Services Health Insurance Portability and Accountability Act Healthcare Common Procedure Coding System Health maintenance Organizations Health Level-7 Managed Care Organizations Medicaid Information Technology system National Provider Identifier Office of Civil Rights Preferred Provider Organizations Point of Service Pharmacy Benefit Managers Primary Care Physician Procedure Coding System
PPACA ECI	Patient Protection and Affordable Care Act External Cause of Injury
PRV	Patient’s Reason for Visit
PHI ICD-9	Protected Health Information International Classification of Diseases 9th Edition
ICD-10 IPPS TPA TPO TR3	International Classification of Diseases 10th Edition Inpatient Prospective Payment System Third Party Administrator Third Party Organization Type3 Technical Report

   VHA             Veterans Health Administration

Branching of healthcare

Health Insurance - Overview

1. What is Health Insurance

·         Health insurance is insurance against the risk of incurring medical expenses.

·         By estimating the overall risk of health care expenses, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is available to pay for the health care benefits specified in the insurance agreement.

·         The benefit is administered by a central organization such as a government agency, private business, or not-for profit entity.

Need for Health Insurance

·         Plan and control the cost of medical care and treatment

·         Proper and timely medical care in case of emergencies

·         Stay healthy by regular and routine checkups.

What you need to know

·         Understand various types of private health insurance that are available

·         Differences between health insurance plans (HMOs, PPOs, and POS)

·         Become familiar with common health insurance provisions, including limitations, exclusions, and riders.

While shopping for healthcare coverage – Here’s is what to consider when picking the Best Individual Health Insurance Policy: 7-Keys

1.      Your “must-haves”

2.      The cost of the basics.

3.      Provide networks.

4.      Out-of-pocket maximums.

5.      Prescriptions

6.      Annual limits on coverage and services.

7.      Dependents.

Some of health Insurance companies in the country

2. Components of Health Insurance

Various expenses involved with health insurance coverage

·         Premium: The amount the policy-holder or his sponsor (e.g. an employer) pays to the health plan to purchase health coverage.

·         Deductible: The amount that the insured must pay out-of -packet before the health insurer pays its share

For example, Policy –holders might have to pay a $500 deductible per year, before any of their health care is covered by the health insurer, It may take several doctor’s visits or prescription refills before the insured person reaches the deductible and the insurance company starts to pay for care.

·         Co-Payment: The amount that the insured must pay out-of –packet before the health insurer pays for a particular visit or service.

For example, an insured person might pay a $20 co-payment for a doctor’s visit, or to obtain a prescription. A co-payment must be paid each time a particular service is obtained.

·         Coinsurance: instead of, or in addition to, paying a fixed amount up front (a co-payment), the co-insurance is a percentage of the total cost that insured person may also pay.

For example, the member might have to pay 20percent of the cost of a surgery over and above co-payment, while the insurance company pays the other 80Percent.If there is an upper limit on coinsurance, the policy-holder could end up owing very little, or a great deal, depending on the actual costs of the services they obtain

·         Exclusions: Not all services are covered .The insured are generally excepted to pay the full cost of non-covered out of their own pockets

·         Coverage limits: some health insurance policies only pay for health care up to a certain dollar amount .The insured person may be expected to pay any charges in excess of the health plan’s maximum payment for a specific service. In addition, some insurance company schemes have annual or lifetime coverage maximums. In these cases , the health plan will stop payment when they reach the benefit maximum, and the policy-holder must pay all remaining  costs

·         Out-of-pocket maximums: similar to coverage limits, except that in this case, the insured pays full further costs. Out-of-Pocket maximums can be limited to specific benefit category (Such as prescription drugs) or can apply to all coverage provided during specific benefit year.

·         Capitation: An amount paid by an insurer to a health care provider, for which the provider agrees to treat all members of the insurer.

·         Fee-For-service: Fee-for-service (FFS) is a payment model where services are unbundled and paid for separately. In the health insurance and the health care industries, FFS occurs when health care providers receive a fee for each service such as an office visit, test, procedure, or other health care service.

·         In-Network Provider: A health care provider on a list of providers preselected by the insurer. The insurer will offer discounted coinsurance or co-payments, or additional benefits, to a plan member to see an in-network provider. Generally, Providers in network are providers who have a contract with the insurer to accept rates further discounted from the “usual and customary” charges the insurer pays to out-of-network providers.

·         Prior authorization: A certification or authorization that an insurer provides prior to medical service occurring. Obtaining an authorization means that the insurer is obligated to pay for the service, assuming it matches what was authorized. Many smaller, routine services do not require authorization.

·         Explanation of Benefits: A document that may be sent by an insurer to a patient explaining what was covered for a medical service, and how payment amount and patient responsibility amount were determined.

3. Types of Health Insurance Coverages

Health insurance is meant to cover a variety of medical expenses. The following are covered under majority of policies:

·         Physician Visits

·         Hospitalizations

·         Surgeries

·         Physical Therapy, Occupational Therapy, Speech Therapy

·         Prescription Drugs

·         Preventive Health care

·         Laboratory tests

·         Mental Health

·         Certain Medical Equipment

·         Rehabilitation Costs

·         Dental Care

·         Vision Care

Different ways the health insurance can be obtained:

Individual Health Insurance

·         Is often used by people who do not have the option of group coverage.it allows for a tailor-made policy that fits exactly what the person needs.

·         This type of insurance is usually relatively inexpensive compared to a group plan. The cost of an individual health insurance plan will typically be about half the cost of a group health insurance plan for the same benefit amount.

Group Health Insurance from an Employer

·         Is a much more affordable type of health insurance only when your employer will pay for most or all of the premium(Which many employers will do)

·         Since the premiums are based on the group as a whole, the risk is spread out over many people.

·         These policies are often the most popular type of private health coverage.

·         One of the benefits to group health insurance coverage is that one cannot typically be denied coverage due to preexisting conditions or other problems.

·         There may sometimes be a waiting period if one has not maintained continuous coverage but everyone will be accepted.

Group Health Insurance from a Non Employer Group

·         Is another option to consider for obtaining health coverage

·         For those who have no policy available through work or an inadequate one. Group rates can be obtained from church groups, professional and business associates such as a chamber of commerce.

·         This can help you obtain health insurance if you are unable to obtain an individual health insurance policy due to your health.

·         One of the benefits to group health insurance coverage is that one cannot typically be denied coverage due to preexisting conditions or other problems.

Student Health Insurance

·         Is usually either a temporary health insurance plan offered through the university or college and may sometimes be available through private insurance company.

Short Term Health Insurance

·         Is a plan that as its name implies only offers coverage for a short amount of time, usually anywhere from 1 month to 1 year (although some short term plans offer coverage up to 3 years).

·         Although short term health insurance plans are typically very cheap; they are also typically very bare coverage and should never be relied upon as along term solution to finding affordable health insurance coverage.

COBRA (Consolidated Omnibus Budget Reconciliation Act):

·         COBRA stands for the Consolidated Omnibus Budget Reconciliation Act. COBRA gives you the right to choose to keep the group health insurance benefits.

·         COBRA also let family members choose to keep health insurance after job loss or other qualifying event that would normally cause them to lose the coverage they have through you employer.

·         In most cases, you can keep the insurance for up to 18 months. Some people may be able keep it a few months longer

·        Qualifying events for the spouse or dependents of the employee who had been included on the employee’s health plan include:

·         The insured employee’s death

·         Divorce or legal separation from the insured employee

·         Loss of dependent status(as defined by the insurance plan’s rules)

·         Employee becomes entitled to Medicare and the employer takes him or her off the health insurance plan

·         Any event in the list above that causes the employee to lose health coverage