Healthcare business analysis concepts

US Health Insurance Concepts
BA Healthcare training – batrainingexcel@gmail.com, baexcel.com

US Health care Segments
Payers
Members
Providers
Benefit Plans
Benefit
Products
Benefit
Services

Payer workflow
Network Building
Benefits and
Enrolment
Management
Billing and Claims
Management
(RCM)
Eligibility &
Authorization
Introduction
Payer Types
Plan Types
Provider
Contracting
Fee schedule
Management
Provider
Credentialing
Provider Directory
Management
Benefit plan
building
Enrolment
Management
Member Eligibility
Management
Member
Authorization
Management
Claims Inward &
Process
Management
Claims Payment
Customer Service
Management
(Appeals)

Members workflow
Appointment Sch,
Eligibility ,
Authorization
Benefit Plan
Selection
Claims
Reimbursement
(RCM)
Member Medical
Care
Introduction
Member Types
Provider
Appointment PCP /
Specialty Care
Employer Funded
Plans
Out-patient
Medical Service
Claims Inward &
Process
Management
Self Funded Plans
Enrolment Period
Insurance
Responsibilities
Member
Responsibilities
Health Plan
Exchange
Eligibility
Verification
In-patient Medical
Service
Ambulatory
Medical Service
Patient Encounter
Pre-Encounter Post-Encounter
Authorization
Request

Provider Workflow
Patient Eligibility,
Authorization and
Admission
Payer Contracting
and Carrier
Directory Mgmt
Revenue Cycle
Management
Patient Care
Management
Introduction
Provider Types Carrier Types
Contracting
Eligibility
Verification
Authorization
Request
Patient Admission
Out-patient
Medical Service
Medical
Transcription
Medical Coding
Medical Billing
Claim Submission
(EDI /Manual)
Claim
Reimumbersement
Follow-up
In-Patient Medical
Service
EMR/EHR
HL7 Integration

US Health Care Standard Codes and EDI formats
Transactional Data
Exchange
(ANSI X12)
Medical Data
ICD Codes
837 Claim
Submission
CPT Codes
HCPCS
HL7
835 Claim Payment
Advice (Remittance
Advice)
276 Claim Status
Enquiry
834 Benefit
enrolment and
maintenance
277 Claim Status
Response
270 Eligibility /
Benefit enquiry
271 Eligibility /
Benefit Response
ANSI ASC X12:
American National Standards Institute,
Accredited Standards Committee X12,
which comprises government and
industry members who create EDI
standards for submission to ANSI for
approval and dissemination.

Payer Introduction
managed care organization Health insurance A health care delivery system consisting of affiliated and/or owned hospitals,
physicians and others which provide a wide range of coordinated health services; an umbrella term for health plans that
provide health care in return for a predetermined monthly fee and coordinate care through a defined network of
physicians and hospitals Examples HMO, POS. See HMO, Point of service plan, PPOs.

Healthcare Payer - Payer Types
Commercial and Blues Carriers:
Commercial carriers are generally national in their geographic scope and offer both group and individual plans.
Medicare Parts A and B
Medicare is a federal health insurance program that provides coverage for people over the age of 65, blind or disabled
individuals, and people with permanent kidney failure or end-stage renal disease.
The Medicare program is administered by the “Centers for Medicare and Medicaid Services (CMS) ” and pays only for
medical services and procedures that have been determined as "reasonable and necessary."
Medicare Part A covers inpatient hospital services and certain follow-up care. This includes the cost of lab tests, x-rays,
nursing services, meals, semi-private rooms, medical supplies, medications, necessary appliances, and operating and
recovery rooms. Medicare Part A also covers home healthcare, although there are strict eligibility requirements.
Medicare Part B covers physicians' services and supplies not covered by Part A. Enrolees must pay a monthly premium
that is set by the federal government.
Medicare Part C : Medicare advantage plan, offered by private insurance carriers.
Medicare Part D : Medicare part D plans are private insurance plans for prescription drug coverage.

Healthcare Payer - Payer Types
Medicaid:
Medicaid is a health insurance assistance program for some low-income people (especially children and pregnant women)
sponsored by both the federal and state governments, although it is administered on a state-by-state basis.
Coverage varies from state to state but each state program must adhere to certain federal guidelines. Some states require
Medicaid beneficiaries to join managed care plans

Healthcare Payer - Plan Types
Payers would offer different type of plans and sell it with low/ high premium’s based on benefits provided to their plan members.
Low premium plans will have high patient responsibilities, i.e. high deductibles, co-pay and co-insurances where as high premium will have
minimal patient responsibilities.
Below are the different type of plans offered by commercial / Non-Profit healthcare insurance payers:
• Preferred Provider Organizations (PPOs):
PPOs gives the member’s choice to their members in getting care from both in network or out-of-network providers.
Less patient responsibilities would be assigned to claim when member visits in-network providers and have higher out of pocket expenses
when visits with out-network hospital with this type plans.
Member can visit to out-network provider without any referral from PCP – Primary Care Provider.
• Point-of-Service (POS) Plans:
POS plans let member’s get medical care from both in-network and out-of-network providers.
Referral from Participating Primary care physician required to visit to Specialist provider.
Higher out-of-pocket expenses may be charged when go to out network providers.

Healthcare Payer - Plan Types
• Health Maintenance Organizations (HMOs):
With HMOs plan members can only take medical services from in-network providers, may be accepted for emergency services.
Referral from Primary Care Physician Required to visit to Specialist provider.
• Exclusive Provider Organizations (EPOs):
EPOs generally limit coverage to care from providers in the EPO’s network (except in an emergency).

Healthcare Payer - Benefit Plan Building
Individual and Family Health Plans : Payers / Managed care organizations will offer Individual and Family Health Plans
Health Plan benefits:
• Medical – Inpatient and out patient medical benefits
• Dental – Inpatient and Outpatient dental care benefits
• Vision – Vision care
• Drugs / Pharmacy – Prescription medicine
Patient Responsibilities
• Co-pay – Fixed amount to be paid to care provider for each visit
• Co-Insurance – Medical care costs would be shared by multiple plans given by multiple insurance providers
• Deductible – Fixed amount of $ for which patient to pay before Insurance start payment
• ( This will be calculated after co-pay and Co-Insurance)
All these benefits are based on
Insurance Premium and Patient
responsibility assignment

Healthcare Payer - Enrolment Management
New Member Enrolment
Processing new member application and approve member plan
Existing Member Enrolment / Renewal
Processing existing member application and approve member plan
Open Enrolment Period:
The yearly period when people can enroll in a health insurance plan. Open Enrollment for 2017 runs from November 1,
2016 to January 31, 2017.
Outside the Open Enrolment Period, People generally can enroll in a health insurance plan only if they qualify for a Special
Enrollment Period.
Eligible if they have certain life events, like getting married, having a baby, or losing other health coverage.
Healthcare Member Enrollment workflow

Healthcare Payer - Network Building
Payer or Managed Care Organization will have contracted providers includes medical professionals, i.e. doctors,
psychologists, or physical therapists, and health care facilities like hospitals, urgent care clinics, or pharmacies to
provide medical services to their members.
Payers would contract with Medical Services providers
with agreed payment terms and conditions.
In-network providers will accept the patients from
Payers with active member plans.
Post patient services are provided, claims submitted by
In-network providers would be paid with agreed
payment terms.
If the medical professionals are not part of the
network and members visit their locations, then they
will be called as out-network providers.
Patients may have to pay higher patient
responsibilities when they visit out-network providers,
payers may or may not pay the claims depends upon
members plan benefits.
Contracted Rates Billed Rates /
Benefit plan
Rates

Healthcare Payer - Provider Contracting
Payers build provider networks with a competitive fee schedule reimbursement strategies.
• Network operations / Contracting team will identify out-network providers by current claims data analysis.
• Contractor will establish the contact with Healthcare provider, post positive response, contracting process would be
initiated.
• Fee schedule discussions would be performed by both parties and agree to one fee schedule.
• Contract sign off would be completed, healthcare provider would be converted to In-Network provider.
• Post contract sign-off, credentialing activities would be proceeded.
• Post credential approval, Fee-schedule / Payment terms would be configured in claims management systems.
• All future claims submitted by Healthcare provider would be processed with agreed payment terms.

Healthcare Payer - Fee Schedule Management
A fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers.
This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service
basis.
CMS develops fee schedules for physicians, ambulance services, clinical laboratory services, and durable medical
equipment, prosthetics, orthotics, and supplies.
Commercial and Non-Profit payers would use CMS Fee-schedule as a base to negotiate with health care service
providers to bring them as part of their network.
Fee schedule is formed using following codes and different rates are formed by the payers which are used to reimburse
the claims.
• ASA – American Society of Anaesthesiologists – List of ASA codes used for Anaesthesiology reimbursements.
• CPT - Current Procedural Terminology – List of Codes maintained by AMA (American Medical Association)
• HCPCS – Healthcare Common Procedural Coding System - – List of Codes maintained by AMA (American Medical
Association)

Healthcare Payer - Provider Credentialing
Provider credentialing is a verification process of Healthcare provider information and approve them as a participating/
in-network provider.
Provider’s experience, education, history of frauds, medical board affiliation, Mal practice information details etc...
Would be verified.
Upon successful verification, credentialing committee / team from the payer would approve / deny the credentialing
form.
Application
Documentation
and Submission
Primary Source
Verification
Credentialing
committee
review and
approval
Perform
Provider site
visit if required
Add Provider
tax id and
demo info in
billing and
directory
system
Provider Joins
Health Plan
Network
Credentialing workflow:
All Licences(State, DEA, CDS), Education, Training(Internship, residency, fellowship), current and previous hospital staff
privileges, malpractice insurance coverage( last five years), claims history, work history and any sanctions with Medicare
and Medicaid.

Healthcare Payer - Provider Directory Management
Insurance payers will maintain and publish provider directories through web.
Directories will help in members:
Finding right network provider based on
• Provider Type (Medical, Dental, Vision and Pharmacy)
• Member plan and coverage type (Commercial, Medicare advantage etc..)
• Location / Zip code
• Specialty
Provider directories would be refreshed (Added / Deleted ) based on contract and credentialing processes.
Members can see the detailed address, working hours, other special services available ( Ex: Wheel chair accessible etc..)

Healthcare Payer - Member Eligibility Verification
Insurance organizations receive verification request from Medical Service Providers to check if Member is eligible for
claim reimbursement and understand about patient responsibilities.
Benefits to Payers:
• Receives clean claims post medical care delivery
• Quicker claim processing
• Avoid over or underpayments
Benefits to providers:
• Avoid partial payments and claim rejections.
• Collect Patient Responsibilities
• Billing to correct insurance provider ( Primary / Secondary
insurance)
• Decreased A/R days
• Cleaner billing system data
• Reduced registration, co-pay and billing errors
• Lower billing and collections costs
ANSI X12 TRANSACTIONS FOR ELIGIBLITY
VERIFICATION
270 – Eligibility Verification Enquiry
270 – Eligibility Verification Response
• Effective date and coverage details
• Type of plan
• Payable benefits
• Co-pay
• Deductibles
• Co-insurance
• Claims mailing address
• Referrals & pre-authorizations
• Pre-existing clause
• Life time maximum
• Other related information

Healthcare Payer - Member Authorization Management
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical
equipment is medically necessary.
Sometimes called prior authorization, prior approval or precertification. Health insurance or plan may require
preauthorization for certain services before you receive them, except in an emergency.
Preauthorization isn’t a promise health insurance or plan will cover the cost
Patient
Enquiry /
Appointment
Primary
Investigations
Finalize
Diagnosis
Collect
Insurance
Details
Enquire If
Authorization
required
Send
Authorization
Request to
Payer
Receive
Response
from Payer
Proceed with
Medical Care
Authorization workflow:

Healthcare Payer - Claims Management
An itemized statement of services and costs from a health care provider or facility submitted to the insured for payment.
Claims are generated and sent by providers to payers either in Electronic or Paper Format.
What is claim:
Provider
provides
services to
patients
Generate
Claims and
Send to Payers
(Electronic /
Paper)
By direct or
from Clearing
Houses
Claims
received by
Payers
Claims data
captured and
upload to
Adjudication
systems.
Pre-validation
of data and
Adjudicate
claim as per
Payer contract
and Member
Plan benefits
Process claim
and complete
Payment
(Reject /
Partial
payment/ Full
payment)
Claim Processing Workflow:

Healthcare Payer - Claims Payment
Payers process claims as per the Agreement / Contract and Member benefits.
Payers sends Payment Remittance Advice / EOB (Explanation of Benefits) post claim processing.
Payer reimburse the claim with
• FULL PAYMENT
• PARTIAL PAYMENT
• ZERO PAYMENT
• REJECT

Healthcare Payer - Customer Service Management
Payer provides customer service to handle queries in various stages of Member and Provider Services
Member Enrolment Provider Search Plan details
Claims and
Payments
Member
wellness
Provider Contracting Networking Credentialing
Health Care
Services
Claims and
Correspondence
Legal and HIPAA
adherence

Member- Member Types
• Employee Sponsored Insurance Members(Self funded / Insurance carrier)
• Insurance would be sponsored by Employer as part of the employee benefits
• Individual / Self-funded Insurance Members
• Members buy the insurance plan on their own
• Responsible to pay premium on their own.

Member- Insurance Responsibilities
Patient Responsibilities
• Co-pay – Fixed amount to be paid to care provider for each visit
• Co-Insurance – Medical care costs would be shared by multiple plans given by multiple insurance providers
• Deductible – Fixed amount of $ for which patient to pay before Insurance start payment
• ( This will be calculated after co-pay and Co-Insurance)
Insurance Responsibilities
• Claim Reimbursement – Pay claim reimbursement at agreed health plan benefits and contract signed with
healthcare provider

Employer Funded Insurance Plans
• The company pays a premium to the insurance carrier.
• The premium rates are fixed for a year, based on the number of employees enrolled in the plan each month.
• The monthly premium only changes during the year if the number of enrolled employees in the plan changes.
• The insurance carrier collects the premiums and pays the health care claims based on the coverage benefits
outlined in the policy purchased.
• The covered persons (eg: employees and dependents) are responsible to pay any deductible amounts or co-
payments required for covered services under the policy.

Employer Funded Self Insurance Plans
With a self-insured (self-funded) health plan, employers (usually larger) operate their own health plan as opposed to
purchasing a fully-insured plan from an insurance carrier.
Employers choose to self-insure because it allows them to save the profit margin that an insurance company adds to its
premium for a fully-insured plan.
Self-insuring exposes the company to much larger risk in the event that more claims than expected must be paid.
With a self-funded health plan there are two main costs to consider: FIXED COSTS and VARIABLE COSTS.
• Fixed costs:
• Administrative Fees
• Any other fees charged per employee
• Stop-loss Premiums
These costs are billed monthly by the TPA or carrier, and are charged based on plan enrolment.
• Variable costs:
• Payment of health care claims (Depends on health care use by Employees and their dependents)
• Stop-loss premium increment for excess usage than pre-determined level.

Member- Health Plan Exchange
A health insurance Marketplace, also known as an exchange, is where you can shop for and compare insurance plans in
your state.
Members can do it online, through an insurance broker, or by phone.
State's Marketplace has tools to help you compare multiple insurance choices and pick the plan required.
In a state Marketplace, health plans are grouped by levels of coverage -- how much they will pay toward the cost of
your health care and what services are covered.
Each level is named after a metal:
• Bronze
• Silver
• Gold
• Platinum

Member- Benefit Plan Enrolment Period
• Platinum: Covers 90% on average of your medical costs; you pay 10%
• Gold: Covers 80% on average of your medical costs; you pay 20%
• Silver: Covers 70% on average of your medical costs; you pay 30%
• Bronze: Covers 60% on average of your medical costs; you pay 40%
Open Enrolment Period:
The yearly period when people can enroll in a health insurance plan. Open Enrollment for 2017 runs from November 1,
2016 to January 31, 2017.
Outside the Open Enrolment Period, People generally can enroll in a health insurance plan only if they qualify for a
Special Enrollment Period.
Eligible if they have certain life events, like getting married, having a baby, or losing other health coverage.

Member- Provider Appointment Booking and Patient Registration
Insurance Member find a health care provider through directories and collect contact information.
Member can also find contact information on Insurance card
Member can book the appointment either through Phone call, Email or Online booking.
Collect
Contact
Information
Schedule
Appointme
nt
Reach to
health care
facility on
time
Fill forms
provided in
Patient
Helpdesk
Patient
registration
Eligibility
enquiry and
Confirmatio
n
Authorrizati
on
Health care
service
Workflow:

Member- Eligibility Verification
• Effective date and coverage details
• Type of plan
• Payable benefits
• Co-pay
• Deductibles
• Co-insurance
• Claims mailing address
• Referrals & pre-authorizations
• Pre-existing clause
• Life time maximum
• Other related information
Member need to submit below required details at Health care facility in order to complete Eligibility verification.

Member- Authorization/Pre-Certification Request
PRIOR AUTHORIZATION
The approval by an insurer or other third-party payor of a health care service before the service is rendered. This approval
is required in order for the insurer to pay the provider for the service.
Patient Visit
Physician / Hospital
Prescriber
• Writes prescription and Q&A
• Submit PA Request
• Transmits Prescription
Payer
• Determines PA Status
• Determines criteria and rules
• Process PA Requests
• Process DRUG Claims
Pharmacy
• Obtains Pharmacy PA
• Dispense DRUGS
• Files DRUG Claims
Health Care Provider
• Obtains Covered
Services PA
• Provide Services
• Files HCFA / UB Claims

Member- Out-patient/In-Patient Admission and care
• Inpatient:
• Inpatient care generally refers to any medical service that requires admission into a hospital.
• Inpatient care tends to be directed towards more serious ailments and trauma that require one or more
days of overnight stay at a hospital. For the purposes of healthcare coverage, health insurance plans
require you to be formally admitted into a hospital for a stay for a service to be considered inpatient.
• Outpatient:
• Outpatient care, on the other hand, is medical service provided that does not require a prolonged stay
at a facility. This can include routine services such as check-ups or visits to clinics.

Member- Member Medical Care
Primary care:
Primary Care includes the diagnosis, treatment and management of general medical conditions. Emphasis is on prevention through
immunizations, wellness check-ups, screening services and education of patients. It is usually provided by family practice doctors,
internists or general practitioners. The primary care physician focuses on wellness and
providing routine care.
Specialty Care:
Specialty Care is care focused on dealing with the diagnosis and treatment of specific, non-routine conditions. Medical services are
received from specialists or physicians with additional training and education in a particular field of medicine such as cardiology, surgery,
oncology or orthopaedics.
Acute Care:
Acute Care refers to the intensive services provided in a hospital setting or outpatient care facility, for serious or complex conditions.
Emergency Care
Emergency Care refers to intensive services given in an emergency room or emergency care center. Care is administered to stabilize a
patient’s medical condition and/or prevent loss of life or worsening of the condition.
Chronic Care
Chronic Care refers to non-acute care usually delivered in a nursing home, or out-patient setting such as clinics, or by a home care
organization. Care needed is for a long-term duration for chronic, recurring conditions. An example would be skin ulcer therapy in a
diabetic patient administered in the home by a licensed nurse.

Member- Member Claim Request , Reimbursement and Self Pay
• Post patient discharge, hospital will collate all necessary information to send Claim .
• Provider (Hospital / Physician) would collect co-pay as per the benefit plan rule.
• Complete all claim form formalities and send claim to Primary Insurance Provider of Patient.
• Hospital do follow-up and receive claim reimbursement along with EOB (explanation of benefits)
• Hospital start follow-up with members to collect patient responsibilities (Self pay collections)

Provider - Introduction
Provider Contracting Networking Credentialing
Health Care
Services
Claims and
Correspondence
Legal and HIPAA
adherence
Provider Workflow

A doctor’s office is a medical facility where one
or more doctors provide treatment to patients.
Doctor’s offices are often focused on one type of
medicine; the health providers operating there
are either general practitioners or practice a
common specialty.
Doctor’s offices provide routine care as well as
treatment for acute conditions that do not
require immediate intervention.
In many cases, physician assistants and nurses
also contribute to the delivery of patient care
Doctors office
A hospital’s primary task is to provide short-term
care for people with severe health issues
resulting from injury, disease or genetic anomaly.
Open 24 hours a day, seven days a week,
hospitals bring together physicians in assorted
specialties, a highly skilled nursing staff, various
medical technicians, health care administrators
and specialized equipment to deliver care to
people with acute and chronic health conditions.
Hospital

Ambulatory surgical centres are designed to
provide simple procedures.
They Also referred to as outpatient or same day
surgery centers, these facilities offer a safe
environment for the surgery and basic
monitoring during the initial post-operation
hours.
Ambulatory Surgical Center
When patients are unable to get to their doctor’s
office or want basic medical care without an
appointment, an urgent care clinic might be the
perfect choice.
Sometimes called walk-in clinics, these facilities
offer outpatient care immediately. However, it is
important to note that an urgent care clinic is not
the same as a hospital’s emergency room.
Urgent Care Clinic

A nursing home is designed for patients who require
constant care but do not need to be hospitalized and
cannot be cared for at home.
Often associated with seniors who require custodial
care in a residential facility, it can actually serve
patients of all ages who require this level of care.
Nursing homes have medical personal onsite 24 hours
a day. A physician, skilled nurses and therapists are on
staff to oversee and provide medical care, assistance
with medications, and services like physical, speech
and occupational therapy.
Nursing Home

Primary Care
PRIMARY CARE
A primary care provider (PCP) is a person you may see first for checkups and health problems.
PCP Doctor types are Family Practice and General medicine.

Specialty Care
• Allergy and asthma
• Anaesthesiology -- general anaesthesia or spinal
block for surgeries and some forms of pain control
• Cardiology -- heart disorders
• Dermatology -- skin disorders
• Endocrinology -- hormonal and metabolic disorders,
including diabetes
• Gastroenterology -- digestive system disorders
• General surgery -- common surgeries involving any
part of the body
• Hematology -- blood disorders
• Immunology -- disorders of the immune system
Primary care provider may refer you to professionals in various
specialties when necessary, such as:
• Obstetrics/gynecology -- pregnancy and women's reproductive
disorders
• Oncology -- cancer treatment
• Ophthalmology -- eye disorders and surgery
• Orthopedics -- bone and connective tissue disorders
• Otorhinolaryngology -- ear, nose, and throat (ENT) disorders
• Psychiatry -- emotional or mental disorders
• Pulmonary (lung) -- respiratory tract disorders
• Radiology -- x-rays and related procedures (such as ultrasound, CT, and
MRI)
• Rheumatology -- pain and other symptoms related to joints and other
parts of the musculoskeletal system
• Urology -- disorders of the male reproductive system and urinary tract
and the female urinary tract

Provider - Carrier Types
Every hospital maintains carrier directory with multiple insurance providers:
• Govt insurance : Medicare, Medicaid and Charity Care
• Commerical – Non Profit – Blue cross blue shield
• Commercial / IPA Networks – Commerical Managed care orgnaizations and for profit insurance companies
(Ex: Humana, Aethna, United healthcare etc.…
Hospitals form their Financial/ collection strategy based on carrier directory they have

Provider - Contracting and Negotiation with Payers
Hospitals or Doctors office maintain their in network relationship with multiple Payers and also particiate in Govt health plans
Contract with
Payers
Agreed fee
schedule
Contracting
with Payers
Become In-
Network
Providers
Service
Insurance
Plan
Members
Healthcare providers bill with agreed rates post joining as a in-network providers.

Provider - Introduction to EMR / EHR
Electronic Medical Record:
This term refers to computer software that health care providers use it to track all aspects of patient care.
The EMR or electronic medical record refers to everything you’d find in a paper chart, such as
• Medical history
• Diagnoses
• Medications
• Immunization dates
• Allergies
EMRs work well within a practice, they’re limited because they don’t easily travel outside the practice.
In fact, the patient’s medical record might even have to be printed out and mailed for another provider to see it.

Electronic Health Record:
EHR or electronic health record are digital records of health information.
EHR contain all the information we see in a paper chart.
EHR Includes past medical history of the patient medical and administrative data which includes:
Medical data :
• LAST PATIENT VISITS
• VITAL SIGNS
• PROGRESS NOTES
• DIAGNOSES
• MEDICATIONS
• IMMUNIZATION DATES
• ALLERGIES
• LAB DATA
• IMAGING REPORTS
Non - Medical data :
• Demographics
• Emergency contact info
• Insurance Information
• Data from the well ness devise
• DME issued etc..

Electronic Health Record:
An EHR is also necessary to meet Meaningful Use requirements.
Meaningful Use is a Medicare and Medicaid program that supports the use of an EHR to improve patient care.
To achieve Meaningful Use and avoid penalties on Medicare and Medicaid reimbursements, eligible providers must
follow a set of criteria that serve as a roadmap for effectively using an EHR.
• An electronic health record (EHR) makes health information instantly accessible to authorized providers across
practices and health organizations.
• It contains a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies,
radiology images, and lab results, among other medical information.
• EHRs are the future of healthcare because they provide critical data that informs clinical decisions, and they help
coordinate care between all providers in the healthcare ecosystem.

EHR (electronic health record) EMR (electronic medical records)
A digital record of health information A digital version of a chart
Streamlined sharing of updated, real-
time information
Not designed to be shared outside the
individual practice
Allows a patient’s medical information
to move with them
Patient record does not easily travel
outside the practice
Access to tools that providers can use
for decision making
Mainly used by providers for diagnosis
and treatment
Differences between EHR and EMR

Potential Benefits of an EHR
Potential Productivity and Financial Improvement
• Fewer chart pulls
• Improved efficiency of handling telephone messages and
medication refills
• Improved billing
• Reduced transcription costs
• Increased formulary compliance and clearer prescriptions
leading to fewer pharmacy call backs
• Improved coding of visits
Quality of Care Improvement
• Easier preventive care leading to increased preventive care
services
• Point-of-care decision support
• Rapid and remote access to patient information
• Easier chronic disease management
• Integration of evidence-based clinical guideline
Job satisfaction Improvement
• Fewer repetitive, tedious tasks
• Less "chart chasing"
• Improved intra-office communication
• Access to patient information while on-call or at the
hospital
• Easier compliance with regulations
• Demonstrable high-quality care
Customer satisfaction Improvement
• Quick access to their records
• Reduced turn-around time for telephone messages and
medication refills
• A more efficient office leads to improved care access for
patients
• Improved continuity of care (fewer visits without the
chart)
• Improved delivery of patient education materials

Integrated Systems - Introduction
Need for Integrated systems
Doctors need to be connected with each other
– especially during transfer of care

Doctors need to be connected with pharmacists
– reduce harmful errors

Hospitals need to be connected with each other
– Especially for medical records transfer

Laboratories need to be connected to
the patient’s electronic health record
Doctors need to be connected to the
patient’s personal health record

Health Information Exchange types

Provider - Introduction to HL7
Health Level 7 (HL7)
HL7 (Health Level Seven International) is a set of standards, formats and definitions for exchanging and
developing electronic health records (EHRs).
HL7 helps to create stronger legal interoperability standards for the healthcare IT industry.
HL7 is a messaging standard that enables clinical applications to exchange data.

Provider - Introduction to HL7
HL7 Message Types
HL7 messages transmit data between disparate systems.
An HL7 message consists of a group of segments in a defined sequence, with these segments or groups of segments
being optional, required, and/or repeatable.
Most commonly used HL7 message types include:
• ACK – General acknowledgement
• ADT – Admit discharge transer
• BAR – Add/change billing account
• DFT – Detailed financial transaction
• MDM – Medical document management
• MFN – Master files notification
• ORM – Order (Pharmacy/treatment)
• ORU – Observation result (unsolicited)
• QRY – Query, original mode
• RAS – Pharmacy/treatment administration
• RDE – Pharmacy/treatment encoded order
• RGV – Pharmacy/treatment give
• SIU – Scheduling information unsolicited

Provider - Revenue Cycle Management
What is Revenue Cycle Management (RCM)
Revenue cycle management (RCM) is the financial process that healthcare facilities use to
track patient care episodes from registration and appointment scheduling to the final
payment of a balance.
It manages claims processing, payment and revenue generation.
It entails using technology to keep track of the claims process at every point of its life .

Provider - Revenue Cycle Management
Revenue Cycle Management (RCM) Workflow
Patient
Registrati
on
Eligibility
and
Authoriza
tion
Medical
documen
tation(Tra
nscriptio
n)
Medical
coding
Charge
PostingClaim
scrubbing
and
submissi
on
Clearing
House
Claim
Transfer
Denial
Manage
ment
Payment
Posting
Appeal
Procedur
e
Bad Debt
Closure
1
2
3
4
5
6
7
8
9
10
11

Provider – Medical Services Documentation / Transcription
Medical transcription (MT) is the manual processing of voice reports dictated by physicians and other healthcare
professionals into text format.
Healthcare providers voice-record their notes and transcriptionists convert the voice files to text, typically in digital
format.
Electronic data is increasingly required for compliance with Health IT and electronic health record (EHR) initiatives.
Voice streaming is sometimes used so voice files can reach the MT department for immediate transcription.
Speech recognition is reducing the need for manual transcription but speech recognition software is still not accurate
enough to replace a human transcriptionist.
Medical Transcription Definition

Provider – Medical Services Documentation / Transcription
Example : Sample Emergency room report:
The patient was seen by me at approximately 4:30 a.m. on the 17th of September 1995.
CHIEF COMPLAINT: The patient complains of chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a 20-year-old male who states that he has had two previous myocardial infarctions related to his use of amphetamines. The patient has not used amphetamines for at
least four to five months, according to the patient; however, he had onset of chest pain this evening.
The patient describes the pain as midsternal pain, a burning type sensation that lasted several seconds. The patient took one of his own nitroglycerin tablets without any relief. The patient became concerned and
came into the emergency department.
Here in the emergency department, the patient states that his pain is a 1 on a scale of 1 to 10. He feels much more comfortable. He denies any shortness of breath or dizziness, and states that the pain feels unlike the
pain of his myocardial infarction. The patient has no other complaints at this time.
PAST MEDICAL HISTORY: The patient's past medical history is significant for status post myocardial infarction in February of 1995 and again in late February of 1995. Both were related to illegal use of amphetamines.
ALLERGIES: None.
CURRENT MEDICATIONS: Include nitroglycerin p.r.n.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 131/76, pulse 50, respirations 18, temperature 96.5.
GENERAL: The patient is a well-developed, well-nourished white male in no acute distress. The patient is alert and oriented x 3 and lying comfortably on the bed.
HEENT: Atraumatic, normocephalic. The pupils are equal, round, and reactive. Extraocular movements are intact.
NECK: Supple with full range of motion. No rigidity or meningismus.
CHEST: Nontender.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm. No murmur, S3, or S4.
ABDOMEN: Soft, nondistended, nontender with active bowel sounds. No masses or organomegaly. No costovertebral angle tenderness.
EXTREMITIES: Unremarkable.
NEUROLOGIC: Unremarkable.
EMERGENCY DEPARTMENT LABS: The patient had a CBC, minor chemistry, and cardiac enzymes, all within normal limits. Chest x-ray, as read by me, was normal. Electrocardiogram, as read by me, showed normal
sinus rhythm with no acute ST or T-wave segment changes. There were no acute changes seen on the electrocardiogram. O2 saturation, as interpreted by me, is 99%.
EMERGENCY DEPARTMENT COURSE: The patient had a stable, uncomplicated emergency department course. The patient received 45 cc of Mylanta and 10 cc of viscous lidocaine with complete relief of his chest pain.
The patient had no further complaints and stated that he felt much better shortly thereafter.
AFTERCARE AND DISPOSITION: The patient was discharged from the emergency department in stable, ambulatory, good condition with instructions to use Mylanta for his abdominal pain and to follow up with his
regular doctor in the next one to two days. Otherwise, return to the emergency department as needed for any problem. The patient was given a copy of his labs and his electrocardiogram. The patient was advised to
decrease his level of activity until then. The patient left with final diagnosis of:
FINAL DIAGNOSIS:
1. Evaluation of chest pain.
2. Possible esophageal reflux.

Provider - Medical Coding
Medical Coding Definition
What is Medical Coding?
Medical coding is the transformation of healthcare diagnosis, procedures, medical services, and equipment into
universal medical alphanumeric codes.
The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician's
notes, laboratory and radiologic results, etc.
Medical coding professionals help ensure the codes are applied correctly during the medical billing process, which
includes abstracting the information from documentation, assigning the appropriate codes, and creating a claim to be
paid by insurance carrier
The main task of a medical coders is to review clinical statements and assign standard codes using CPT®, ICD-10-CM,
and HCPCS Level II classification systems

CPT - Current Procedural Terminology
CPT® codes are the United States’ standard for how medical professionals document and report medical, surgical, radiology,
laboratory, anesthesiology, and evaluation and management (E/M) services.
All healthcare providers, payers, and facilities use CPT® codes.
Current Procedural Terminology (CPT®) codes were first published in 1966 and are developed, maintained, and copyrighted by the
American Medical Association (AMA). Thousands of CPT® codes are in use, and they are updated annually. They fall into three
categories:
• Category I – These five-digit codes have descriptors which correspond to a procedure or service. Codes range from 00100 -
99499.
• Category II – These alphanumeric tracking codes are used for execution measurement. Using them is often optional.
• Category III – These are provisional codes for new and developing technology, procedures, and services. The codes were
created for data collection and assessment of new services and procedures.

HCPCS LEVEL II - Healthcare Common Procedure Coding System
HCPCS is an acronym for Healthcare Common Procedure Coding System (HCPCS).
Standardized code sets are necessary for Medicare and other health insurance providers to provide healthcare claims that are
managed consistently and in an orderly manner.
HCPCS Level II coding system is one of several code sets used by healthcare professionals, including medical coders and billers.
The Level I HCPCS code set includes CPT® (Current Procedural Terminology) codes.
CPT is developed and owned by the American Medical Association (AMA).

ICD 10 - International Classification of Diseases
ICD-10 is the 10th revision from the International Classification of Diseases (ICD) and went into effect
for multiple countries on October 1st, 2015.
This revision contains codes for diseases, related health problems, abnormal findings, signs and
symptoms of, external causes of injury or diseases, and social circumstances.
• ICD-10-CM diagnosis coding which is for use in all U.S. health care settings.
• ICD-10-PCS inpatient procedure coding which is for use in U.S. hospital settings.
ICD-10 affects diagnosis and inpatient procedure coding for everyone covered by the Health Insurance
Portability Accountability Act (HIPAA), not just those who submit Medicare or Medicaid claims:
• Claims for services provided on or after the compliance date should be submitted with ICD-10
diagnosis codes.
• Claims for services provided prior to the compliance date should be submitted with ICD-9 diagnosis
codes.

ICD 10 - FACTS

Provider - Claim Submission - Form types
Under HIPAA regulations, standard transactions like claims are required to be submitted electronically.
There are some exceptions to this rule, however. For one, a practice under 10 employees may use manual claims
The two most common claim forms are the
CMS-1500 and the UB-04.
These two forms look and operate similarly, but they are not interchangeable.
The UB-04 is based on the CMS-1500, but is actually a variation on it—it’s also known as the CMS-1450 form.
• CMS-1500 forms are used for non-institutional healthcare facilities (e.g., private practices),
• UB-04 (CMS-1450) forms are generally used in institutional healthcare facilities, such as hospitals.
Health care providers submit claims forms through HEALTH CARE CLEARING HOUSES

CMS 1500 EXAMPLE

UB 04 EXAMPLE

Provider - Clearing Houses - Workflow
Health care clearinghouse means a public or private entity used to process or aid in the processing of health
information received from another entity in a nonstandard format into standard format or nonstandard
data content into standard data content.
Many different types of claims clearinghouses as there are various types of medical claims;
• PHARMACY CLAIMS
• DENTAL CLAIMS
• DME CLAIMS
• IN-PATIENT FACILITY CLAIMS
• OUT-PATIENT MEDICAL PROFESSIONAL CLAIM
Reference : http://clearinghouses.org/
HEALTH CARE CLARING HOUSE

Provider - Claim Reiumbursement and Cash Posting
Insurance Carrier process the claim as per the Patient insurance benefits and Health care provider contract.
Insurance carrier would issue an EOB (Explanation of Benefits ) along with the claim reimbursement.
An EOB does look like a bill. It contains the date of service, the code used to bill a particular service to an
insurance company,
• The fee charged by the healthcare provider,
• The allowed amount under the third-party payers’s contractual fee schedule,
• The patient’s responsibility under the terms of their coverage,
• The payment made by the payer, and the contractual write-off.
• The final entry of each line item is usually the titled something along the lines of, “what you owe,” or, “your
responsibility.”
Hospital RCM staff would perform the cash posting to their Practice management system using EOB and follow-
further steps.

Provider - Claim Follow-up and Bad Debt Recovery / Write-off
Health care providers perform Claim follow-ups for compelte claim reiumbursment in below scenarios :
• Authorization Issues
• Referral Issues
• Medical Necessity and Medical Records requests
• Non-Participation with Insurance Network
• Terminated Insurance
• Coordination of benefits
• Wrong Diagnosis
• Inclusive Procedures
• Partial Payments
• Out-of-network claim status and deductibles
• EDI Rejections
• Letter of Protection from Attorney cases
• No status and No claim on File
• Workers' Compensation

Provider - Claim Follow-up and Bad Debt Recovery / Write-off
The Follow-Up process can happen in multiple methods:
Online Claims Follow-Up – Using various Insurance company websites and internet payer portals we check on the status of
outstanding claims.
Automated Claims Follow-Up (IVR) – By calling Insurance companies directly an Interactive Voice response system will give the
status of unpaid claims.
Insurance Company Representative – If necessary calling a "live" Insurance company representative will give us a more detailed
reason for claim denials when such information is not available from either websites or Automated phone systems.
Once the Follow-Up process has begun Denied Insurance claims will require extra effort for resolution. Denials management is
divided into two categories
Claim Correction and Resubmission: These are the claims which are corrected, modified, and resubmitted as a corrected claim
to Insurance companies. For such claims every effort is made to resolve the denial to avoid billing the Patient.
Patients' responsibility: These are claims which cannot be further worked upon and the final bill is sent to the patient for
payment collection.
The reasons for sending the patient a bill generally include In-Network deductibles and non-covered benefits as per the
insurance plan/policy. Patients will receive a statement with a clear explanation for the balance due.

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