This presentation covers the basics of Healthcare domain and the testing challenges faced there off.Good content for people having interest or working in Health Care domain.
This presentation discusses the key elements of a Corporate Compliance program allowing an organization to self-monitor operations on an ongoing basis to ensure compliance with supportive documentation to adhere to applicable laws and the organization’s own policies and procedures.
Appropriate for CEOs, CFOs, Administrators, Nursing Management, Direct Care Nurses in a SNF, MDS Coordinators and Business Office Managers.
The Skilled Nursing Facility (SNF) “Program for Evaluating Payment Patterns Electronic Report” (PEPPER) was released in April 2014 by CMS. Join Keri Hart, MS, CCC-SLP, CHHRP-QT, RAC-CT, in this in-depth interpretation of the elements of the PEPPER. Keri will detail how to interpret your PEPPER and discuss the practical application of this critical information to your Skilled Nursing Facility’s practice. Follow along with your own PEPPER report to develop an action plan to ensure compliance with Medicare regulatory requirements and ensure accurate reimbursement for clinically appropriate care provided.
CMS introduced this new annual report for Skilled Nursing Facilities in August 2013. PEPPER data is shared with both Medicare Administrative Contractors (MACs) and the Medicare Recovery Audit Contractors (RACs). This important report details your facility-specific Medicare claims data in certain targeted areas and compares your facility to other SNFs Nationally, by State and by Jurisdiction (Medicare Administrative Contractors/Fiscal Intermediaries).
Coding of activities of daily living (ADLs) on the MDS is complex and often misunderstood by those engaged in completing the assessment. In addition to affecting care, public information and survey, this area of the MDS has a tremendous financial impact. This presentation defines late loss ADLs and provide insights aimed at helping facility staff document resident status accurately. Calculating the ADL score for the RUG-IV system is reviewed and implications of inappropriate coding will be demonstrated.
Keep your MMQ and MDS Coordinators up to speed to prepare for Case Mix. Learn MDS 3.0 coding strategies and how to optimize case mix reimbursement. Learn the documentation requirements to support the RUG level achieved.
1. Learn to identify requirements for scheduling OBRA MDS Assessments for Case Mix.
2. Learn to identify Rehabilitation Case Management strategies for Clinically Appropriate placement in RUG-III and RUG-IV Classification categories.
3. Learn to identify Nursing RUG-III and RUG-IV Qualifiers.
4. Learn to identify ADL Documentation strategies.
This presentation covers the basics of Healthcare domain and the testing challenges faced there off.Good content for people having interest or working in Health Care domain.
This presentation discusses the key elements of a Corporate Compliance program allowing an organization to self-monitor operations on an ongoing basis to ensure compliance with supportive documentation to adhere to applicable laws and the organization’s own policies and procedures.
Appropriate for CEOs, CFOs, Administrators, Nursing Management, Direct Care Nurses in a SNF, MDS Coordinators and Business Office Managers.
The Skilled Nursing Facility (SNF) “Program for Evaluating Payment Patterns Electronic Report” (PEPPER) was released in April 2014 by CMS. Join Keri Hart, MS, CCC-SLP, CHHRP-QT, RAC-CT, in this in-depth interpretation of the elements of the PEPPER. Keri will detail how to interpret your PEPPER and discuss the practical application of this critical information to your Skilled Nursing Facility’s practice. Follow along with your own PEPPER report to develop an action plan to ensure compliance with Medicare regulatory requirements and ensure accurate reimbursement for clinically appropriate care provided.
CMS introduced this new annual report for Skilled Nursing Facilities in August 2013. PEPPER data is shared with both Medicare Administrative Contractors (MACs) and the Medicare Recovery Audit Contractors (RACs). This important report details your facility-specific Medicare claims data in certain targeted areas and compares your facility to other SNFs Nationally, by State and by Jurisdiction (Medicare Administrative Contractors/Fiscal Intermediaries).
Coding of activities of daily living (ADLs) on the MDS is complex and often misunderstood by those engaged in completing the assessment. In addition to affecting care, public information and survey, this area of the MDS has a tremendous financial impact. This presentation defines late loss ADLs and provide insights aimed at helping facility staff document resident status accurately. Calculating the ADL score for the RUG-IV system is reviewed and implications of inappropriate coding will be demonstrated.
Keep your MMQ and MDS Coordinators up to speed to prepare for Case Mix. Learn MDS 3.0 coding strategies and how to optimize case mix reimbursement. Learn the documentation requirements to support the RUG level achieved.
1. Learn to identify requirements for scheduling OBRA MDS Assessments for Case Mix.
2. Learn to identify Rehabilitation Case Management strategies for Clinically Appropriate placement in RUG-III and RUG-IV Classification categories.
3. Learn to identify Nursing RUG-III and RUG-IV Qualifiers.
4. Learn to identify ADL Documentation strategies.
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing recent national trends in Medical Review, Reasons for increased review and the various Medical Review programs. The speaker will present specific denial trends with examples of denial statements. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.
Why You Need Health Insurance: - HealthCompareHealth Compare
Are you lost in the maze of confusion information about the price and cost of health insurance and health insurance plans? The experts at HealthCompare put together some slide to help you through the health insurance clutter and make finding the right affordable health insurance easy. HealthCompare.com provides Affordable Health Insurance Quotes and makes it easy to buy Individual Health Insurance, Family Health Insurance and other Health Insurance Plans. http://www.healthcompare.com
PYA Principal Jim Lloyd along with Polsinelli’s Douglas Anning presented “Doing the Deal” in which they utilized case studies in analyzing both hospital-hospital transactions and hospital-physician practice transactions. The presentation also covered:
Helping clients successfully negotiate and structure the transaction and keeping the deal on track
Recognizing sample contract provisions common to these types of deals
Working with valuation firms to ensure the transaction terms are within fair market value and commercially reasonable
Evaluating and dealing with potential anti-trust concerns
Dealing with potential compliance issues identified during the due-diligence process
Can your Skilled Nursing Facility (SNF) afford to provide care to Medicare patients and not receive accurate and appropriate reimbursement? The resources utilized to respond to additional documentation requests, manage denials and the loss of revenue for care provided can have a devastating impact on your facilities budget. In addition, early identification of potential issues and prompt resolution of actual issues reduces a facilities risk of hefty fines and penalties related to non-compliance.
Skilled Nursing Facilities are required to have a compliance program effective March 2013. Compliance programs strengthen and document a SNFs efforts to prevent and reduce Medicare fraud and abuse and ensure accurate and appropriate reimbursement for quality care provided. Under SNF compliance regulations Medicare has redefined the definition of fraud. When a facility has not taken all the necessary steps to ensure all the technical and clinical qualifications are supported by your medical records to prevent improper billing, fines and penalties may be applied. The critical components of an effective compliance program include monitoring and auditing to ensure Skilled Nursing Facility provider's have a formalized and proactive approach towards detecting fraud, abuse, and waste of precious company resources.
A detailed review of changes and updates discussed to the MDS 3.0 item set effective October 1, 2013. The course will provide an overview of the most recent MDS 3.0 User’s Manual updates. The speaker will review key elements for MDS coding, which will impact reimbursement based on the Federal Regulations in the FY 2014 Final Rule.
Under the scrutiny of review, rehabilitation and nursing documentation must support skilled coverage criteria. This presentation covers skilled coverage criteria and documentation by rehabilitation professionals and nursing to support clinically appropriate levels of care.
1. Learn to define skilled coverage criteria.
2. Learn to define key elements of documentation.
3. Learn examples of rehabilitation and nursing documentation to support Medicare coverage criteria.
This New York Medicaid Nursing Facility Case Mix Seminar discusses the necessary documentation needed to support the assigned Medicaid RUG to ensure accurate reimbursement for care provided. New York OMIG Auditors are focused on auditing "high risk" Medicaid Case Mix MDSs for Nursing Facilities with a change in CMI by more than five percent for 2012.
1. Learn to identify the specific components of NY RUG-III 53 categories.
2. Learn to identify high risk NY RUG-III 53 categories.
3. Learn to identify documentation requirements to support the RUG components.
4. Learn to identify strategies for organization of the Medical Record in preparation for OMIG Audits.
The management of the Minimum Data Set (MDS) 3.0 assessment schedule is complex and time consuming. Combining scheduled MDS assessments with unscheduled Prospective Payment System (PPS) Other Medicare Required Assessments (OMRAs) correctly will lead to accurate reimbursement and can ease the MDS workflow burden on the entire team, and save the facility costly mistakes due to noncompliance. Practitioners need to know what to do if the MDS schedule is not followed correctly, and how to regain compliance with the schedule as quickly as possible. This presentation reviews the scheduled and unscheduled PPS assessment requirements and describe how to select and set Assessment Reference Dates (ARDs) strategically and accurately. The presentation also discusses implications of not following the assessment schedule correctly, and how to regain compliance once an error in assessment scheduling is discovered. The Correction Process of existing MDS assessments, including modification, inactivation, and manual correction request will be discussed. This all-important information will help the MDS coordinator to maintain and regain federal compliance with the PPS assessment schedule.
1. Learn to outline the scheduled PPS assessment schedule and unscheduled PPS assessment requirements and explain the correct Assessment Reference Date selection for each assessment type.
2. Learn to state the correct application of default or provider liable days for an early, late, or missed scheduled or unscheduled assessment.
3. Learn to identify the appropriate use of the Start of Therapy OMRA, End of Therapy OMRA, End of Therapy-Resumption OMRA, and Change of Therapy OMRA.
4. Learn the eight criteria for a Medicare Short-Stay assessment.
5. Learn to identify the difference between a MDS modification and a MDS inactivation and recognize when to choose modification or inactivation.
This presentation provides a comprehensive pro-active review of program development for long-term care patients in the SNF. The course outlines suggestions for how rehabilitation team members can strengthen the Medicare Part B programming in the nursing facility. An overview of the Medicare Part B Guidelines, Part B Caps, Functional Limitation G-Codes, and Manual Reviews is also provided. The presentation also discusses Medicare Part B documentation, goal writing and reasons for denied claims.
1. Gain an understanding of Proactive Medicare Part B Program Development and how to strengthen the program components.
2. Gain a better understanding of Medicare Part B documentation components, goal writing and potential risk for receiving denied claims.
3. Gain an understanding of Medicare Part B Guidelines, Medicare Part B Caps, Functional Limitation G-Codes and Medical Reviews.
“Documentation not supportive of the RUG-IV classification billed…” is cited as the reason for multiple post-payment medical record review denials. Accurate and concise documentation to support the RUG-IV classification billed is a critical element in gaining accurate reimbursement, and supporting that reimbursement level during a medical review. This presentation covers the technical and clinical requirements for Medicare coverage, and requirements of skilled nursing documentation. The presentation identifies areas of the MDS 3.0 that are vulnerable to error and critical to accurate RUG-IV classification and identify strategies for better supporting these areas in medical record documentation. The correlation between the MDS 3.0 assessment and publicly reported information for the Quality Measures and 5 Star Quality Reporting are discussed.
1. Learn to describe the technical and clinical requirements for Medicare coverage.
2. Understand the goal of supportive skilled nursing documentation.
3. Develop a clear understanding of accurate coding in Section M.
4. Learn to identify sections of the MDS 3.0 assessment that are vulnerable to error and articulate strategies to support these areas in medical record documentation.
5. Learn to identify the correlation between medical record documentation, the MDS 3.0, and publicly reported information for the Quality Measures and 5 Star Quality Rating.
Coding of activities of daily living (ADLs) on the MDS is complex and often misunderstood by those engaged in completing the assessment. In addition to affecting care, public information and survey, this area of the MDS has a tremendous financial impact. During this session, the speaker will define the late loss ADLs and provide insights aimed at helping facility staff document resident status accurately. Calculating the ADL score for the RUG-IV system will be reviewed and implications of inappropriate coding will be demonstrated. Using dollar-impact case studies, the attendee will learn why this section is critical for the facility’s financial success.
This presentation includes a detailed review of changes and updates discussed to the MDS 3.0 item set effective October 1, 2013. The presentation provides an overview of the most recent MDS 3.0 User’s Manual updates and reviews key elements for MDS coding, which will impact reimbursement based on the Federal Regulations in the FY 2014 Final Rule.
Skilled Nursing Facilities have seen a significant increase in Medicare Part A and Part B Therapy denials. The goal of medical review is to determine whether the services are reasonable and necessary, delivered in the appropriate setting, and coded correctly, based on appropriate documentation. The speaker will begin this seminar by discussing recent national trends in Medical Review, Reasons for increased review and the various Medical Review programs. The speaker will present specific denial trends with examples of denial statements. The presentation will culminate in a review of the keys to responding to a medical record request and appeal tips and strategies.
Why You Need Health Insurance: - HealthCompareHealth Compare
Are you lost in the maze of confusion information about the price and cost of health insurance and health insurance plans? The experts at HealthCompare put together some slide to help you through the health insurance clutter and make finding the right affordable health insurance easy. HealthCompare.com provides Affordable Health Insurance Quotes and makes it easy to buy Individual Health Insurance, Family Health Insurance and other Health Insurance Plans. http://www.healthcompare.com
PYA Principal Jim Lloyd along with Polsinelli’s Douglas Anning presented “Doing the Deal” in which they utilized case studies in analyzing both hospital-hospital transactions and hospital-physician practice transactions. The presentation also covered:
Helping clients successfully negotiate and structure the transaction and keeping the deal on track
Recognizing sample contract provisions common to these types of deals
Working with valuation firms to ensure the transaction terms are within fair market value and commercially reasonable
Evaluating and dealing with potential anti-trust concerns
Dealing with potential compliance issues identified during the due-diligence process
Can your Skilled Nursing Facility (SNF) afford to provide care to Medicare patients and not receive accurate and appropriate reimbursement? The resources utilized to respond to additional documentation requests, manage denials and the loss of revenue for care provided can have a devastating impact on your facilities budget. In addition, early identification of potential issues and prompt resolution of actual issues reduces a facilities risk of hefty fines and penalties related to non-compliance.
Skilled Nursing Facilities are required to have a compliance program effective March 2013. Compliance programs strengthen and document a SNFs efforts to prevent and reduce Medicare fraud and abuse and ensure accurate and appropriate reimbursement for quality care provided. Under SNF compliance regulations Medicare has redefined the definition of fraud. When a facility has not taken all the necessary steps to ensure all the technical and clinical qualifications are supported by your medical records to prevent improper billing, fines and penalties may be applied. The critical components of an effective compliance program include monitoring and auditing to ensure Skilled Nursing Facility provider's have a formalized and proactive approach towards detecting fraud, abuse, and waste of precious company resources.
A detailed review of changes and updates discussed to the MDS 3.0 item set effective October 1, 2013. The course will provide an overview of the most recent MDS 3.0 User’s Manual updates. The speaker will review key elements for MDS coding, which will impact reimbursement based on the Federal Regulations in the FY 2014 Final Rule.
Under the scrutiny of review, rehabilitation and nursing documentation must support skilled coverage criteria. This presentation covers skilled coverage criteria and documentation by rehabilitation professionals and nursing to support clinically appropriate levels of care.
1. Learn to define skilled coverage criteria.
2. Learn to define key elements of documentation.
3. Learn examples of rehabilitation and nursing documentation to support Medicare coverage criteria.
This New York Medicaid Nursing Facility Case Mix Seminar discusses the necessary documentation needed to support the assigned Medicaid RUG to ensure accurate reimbursement for care provided. New York OMIG Auditors are focused on auditing "high risk" Medicaid Case Mix MDSs for Nursing Facilities with a change in CMI by more than five percent for 2012.
1. Learn to identify the specific components of NY RUG-III 53 categories.
2. Learn to identify high risk NY RUG-III 53 categories.
3. Learn to identify documentation requirements to support the RUG components.
4. Learn to identify strategies for organization of the Medical Record in preparation for OMIG Audits.
The management of the Minimum Data Set (MDS) 3.0 assessment schedule is complex and time consuming. Combining scheduled MDS assessments with unscheduled Prospective Payment System (PPS) Other Medicare Required Assessments (OMRAs) correctly will lead to accurate reimbursement and can ease the MDS workflow burden on the entire team, and save the facility costly mistakes due to noncompliance. Practitioners need to know what to do if the MDS schedule is not followed correctly, and how to regain compliance with the schedule as quickly as possible. This presentation reviews the scheduled and unscheduled PPS assessment requirements and describe how to select and set Assessment Reference Dates (ARDs) strategically and accurately. The presentation also discusses implications of not following the assessment schedule correctly, and how to regain compliance once an error in assessment scheduling is discovered. The Correction Process of existing MDS assessments, including modification, inactivation, and manual correction request will be discussed. This all-important information will help the MDS coordinator to maintain and regain federal compliance with the PPS assessment schedule.
1. Learn to outline the scheduled PPS assessment schedule and unscheduled PPS assessment requirements and explain the correct Assessment Reference Date selection for each assessment type.
2. Learn to state the correct application of default or provider liable days for an early, late, or missed scheduled or unscheduled assessment.
3. Learn to identify the appropriate use of the Start of Therapy OMRA, End of Therapy OMRA, End of Therapy-Resumption OMRA, and Change of Therapy OMRA.
4. Learn the eight criteria for a Medicare Short-Stay assessment.
5. Learn to identify the difference between a MDS modification and a MDS inactivation and recognize when to choose modification or inactivation.
This presentation provides a comprehensive pro-active review of program development for long-term care patients in the SNF. The course outlines suggestions for how rehabilitation team members can strengthen the Medicare Part B programming in the nursing facility. An overview of the Medicare Part B Guidelines, Part B Caps, Functional Limitation G-Codes, and Manual Reviews is also provided. The presentation also discusses Medicare Part B documentation, goal writing and reasons for denied claims.
1. Gain an understanding of Proactive Medicare Part B Program Development and how to strengthen the program components.
2. Gain a better understanding of Medicare Part B documentation components, goal writing and potential risk for receiving denied claims.
3. Gain an understanding of Medicare Part B Guidelines, Medicare Part B Caps, Functional Limitation G-Codes and Medical Reviews.
“Documentation not supportive of the RUG-IV classification billed…” is cited as the reason for multiple post-payment medical record review denials. Accurate and concise documentation to support the RUG-IV classification billed is a critical element in gaining accurate reimbursement, and supporting that reimbursement level during a medical review. This presentation covers the technical and clinical requirements for Medicare coverage, and requirements of skilled nursing documentation. The presentation identifies areas of the MDS 3.0 that are vulnerable to error and critical to accurate RUG-IV classification and identify strategies for better supporting these areas in medical record documentation. The correlation between the MDS 3.0 assessment and publicly reported information for the Quality Measures and 5 Star Quality Reporting are discussed.
1. Learn to describe the technical and clinical requirements for Medicare coverage.
2. Understand the goal of supportive skilled nursing documentation.
3. Develop a clear understanding of accurate coding in Section M.
4. Learn to identify sections of the MDS 3.0 assessment that are vulnerable to error and articulate strategies to support these areas in medical record documentation.
5. Learn to identify the correlation between medical record documentation, the MDS 3.0, and publicly reported information for the Quality Measures and 5 Star Quality Rating.
Coding of activities of daily living (ADLs) on the MDS is complex and often misunderstood by those engaged in completing the assessment. In addition to affecting care, public information and survey, this area of the MDS has a tremendous financial impact. During this session, the speaker will define the late loss ADLs and provide insights aimed at helping facility staff document resident status accurately. Calculating the ADL score for the RUG-IV system will be reviewed and implications of inappropriate coding will be demonstrated. Using dollar-impact case studies, the attendee will learn why this section is critical for the facility’s financial success.
This presentation includes a detailed review of changes and updates discussed to the MDS 3.0 item set effective October 1, 2013. The presentation provides an overview of the most recent MDS 3.0 User’s Manual updates and reviews key elements for MDS coding, which will impact reimbursement based on the Federal Regulations in the FY 2014 Final Rule.
Best practices paper on the risks, standards and challenges of Health Risk Management- Testing in the Healthcare domain by Devi.K from Siemens. Paper submitted during QAI's 12th International Software Testing Conference
H2Kinfosys provides professional training services in Software QA Testing, Business Analysis(BA), Ruby, Rails, Selenium, Watir, JAVA/J2EE, Microsoft .Net technologies (C#, VB,ASP, Crystal Reports etc..), Business Objects, SharePoint, Informatica, Oracle DBA, SQL Server DBA, ASP, BRIO, Advanced Quick Test Pro, Advanced Loadrunner. IBM/Rational Test Manager, Robot, SAP (Basis, Security, XI, CRM, SD, MM, PP, HR, BI/BW, Fi/Co, SEM, SCM,) Software Training, etc. for every one everywhere in the world.
Training with Live Projects and real time scenarios visit http://www.h2kinfosys.com for more details
Muga culture is endemic to Assam and practiced in this region since a long period. This PPT highlights the brief process and practice of Muga culture- form Soil to Silk.
Chapter 18 Private and Government Healthcare Systems PriMorganLudwig40
Chapter 18
Private and Government Healthcare Systems
Private and Government Healthcare Systems
In the United States, health insurance coverage is generally classified as either private (non-government) coverage or government-sponsored coverage.
Healthcare Coverage vs. Uninsured
The National Center for Health Statistics defines health insurance as public and private payers who cover medical expenditures incurred by a defined population in a variety of settings.
In the United States, the risk of becoming uninsured increases significantly for those earning low wages, the unemployed, and when employers are unable to provide insurance to workers.
Table 5-2 presents the trend of declining health insurance coverage.
Private Health Insurance
The concept of insurance is to combine the healthcare experiences of many enrollees in order to reduce expenses for any one individual to a manageable prepayment amount.
Employment-Based Plans is coverage offered through one’s own employment or a relative’s employment.
It may be offered by an employer or by a union.
Private Health Insurance Continued
Direct-Purchase/Fee-For-Service Plans are the traditional type of healthcare policy.
The physician sets a price for each type of service delivered, and then the client or insurance company pays the fee.
This type of health insurance provides the most choices of doctors and hospitals.
Private Health Insurance Continued
The two kinds of fee-for-service coverage are basic and major medical.
Basic covers some hospital services and supplies, such as X-rays and prescribed medicine.
Major medical insurance covers the cost of long-term, high-cost illnesses or injuries plus whatever basic did not cover.
Private Health Insurance Continued
Group Contract Insurance—to make hospitals and physicians products and services affordable to ordinary people in the United States.
With unmanaged care (fee-for-service) payments, healthcare providers could increase the number of single services they deliver in order to increase profit.
Private Health Insurance Continued
Managed Care—manages the cost and delivery of healthcare services, the quality of that healthcare, and access to care.
Managed care influences how much healthcare clients can use.
Health Maintenance Organizations (HMOs) are prepaid health plans.
The goal of an HMO is to provide affordable, well-organized healthcare by allowing clients to prepay (capitation payment) on a regular monthly basis for all services provided.
Private Health Insurance Continued
Including physicians’ visits, hospital stays emergency care, surgery, laboratory (lab) tests, X-rays, and therapy for all members and their families.
There may be a small co-payment for each office visit, such as $15 for a doctor’s visit or $50 for hospital emergency room treatment.
Private Health Insurance Continued
Point-of-Service Plans (POS) offer enrollees the option of receiving services from participating or nonparticipating prov ...
2016 Presentation to the Benefits Committee of the TSA Texas Sign Association on the concept of self-insured group medical stop loss captive for employee health insurance.
Here are 7 Health Insurance Questions, Answered: 1. What Is Health Insurance? 2. Why Do I Need Health Insurance? 3. What Are the Different Types of Health Insurance? 4. What Is a Premium, Deductible, and Copayment?
A for loop is probably the most common type of loop in Python. A for loop will select items from any iterable. In Python an iterable is any container (list, tuple, set, dictionary), as well as many other important objects such as generator function, generator expressions, the results of builtin functions such as filter, map, range and many other items.
JIRA Introduction, What is JIRA, JIRA Training, JIRA Tutorial for beginners | Atlassian JIRA Training in USA
JIRA is a proprietary issue tracking product, developed by Atlassian. It provides bug tracking, issue tracking, and project management functions. Although normally styled JIRA, the product name is not an acronym, but a truncation of Gojira, the Japanese name for Godzilla. It has been developed since 2002.
Contact us:
www.h2kinfosys.com
Email: Training@h2kinfosys.com
USA: +1-770-777-1269
UK: 020-33717615
This sample Test Plan template gives you an idea about how to preparation of Test Plan . Test Plan Templates, Test Plan sample Template and Fundamentals.
QA Interview Questions With Answers from software testing experts. Frequently asked questions in Quality Assurance (QA) interview for freshers and experienced professionals.
The Art Pastor's Guide to Sabbath | Steve ThomasonSteve Thomason
What is the purpose of the Sabbath Law in the Torah. It is interesting to compare how the context of the law shifts from Exodus to Deuteronomy. Who gets to rest, and why?
We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as “distorted thinking”.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
How to Create Map Views in the Odoo 17 ERPCeline George
The map views are useful for providing a geographical representation of data. They allow users to visualize and analyze the data in a more intuitive manner.
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
Ethnobotany and Ethnopharmacology:
Ethnobotany in herbal drug evaluation,
Impact of Ethnobotany in traditional medicine,
New development in herbals,
Bio-prospecting tools for drug discovery,
Role of Ethnopharmacology in drug evaluation,
Reverse Pharmacology.
Palestine last event orientationfvgnh .pptxRaedMohamed3
An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
Students, digital devices and success - Andreas Schleicher - 27 May 2024..pptxEduSkills OECD
Andreas Schleicher presents at the OECD webinar ‘Digital devices in schools: detrimental distraction or secret to success?’ on 27 May 2024. The presentation was based on findings from PISA 2022 results and the webinar helped launch the PISA in Focus ‘Managing screen time: How to protect and equip students against distraction’ https://www.oecd-ilibrary.org/education/managing-screen-time_7c225af4-en and the OECD Education Policy Perspective ‘Students, digital devices and success’ can be found here - https://oe.cd/il/5yV
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
Cambridge International AS A Level Biology Coursebook - EBook (MaryFosbery J...
Health Care Project Overview from H2kInfosys LLC
1. H2K Infosys is business based in Atlanta, Georgia – United States
Providing Online IT training services world wide.
www.H2KINFOSYS.com
USA - +1-(770)-777-1269, UK - (020) 3371 7615USA - +1-(770)-777-1269, UK - (020) 3371 7615
Training@H2KInfosys.com / H2KInfosys@Gmail.comTraining@H2KInfosys.com / H2KInfosys@Gmail.com
1
2. H2K INFOSYS PROVIDES WORLD CLASSH2K INFOSYS PROVIDES WORLD CLASS
SERVICES INSERVICES IN
2
3. 1. Healthcare Overview
2. Key Terminology
3. Major Players of Healthcare
4. Day in the life of a Claim
5. An enrolled Member seeks Medical service
6.Brief discussion on ICD-10 codes
Table of Contents
3
4. Healthcare Overview
4
According to the Health Insurance Portability and Accountability Act or ‘HIPAA’ healthcare is broadly defined and
includes any care, service, or supply related to the mental or physical health of an individual. It is also defined as the
treatment, management and prevention of illness and the preservation of the physical and mental well being of a person
with the help of medical and allied health professionals.
An individual can become a Member and pay regular premiums to get the healthcare services covered by a health
insurance company.
Members enrolled in health Insurance Company’s healthcare programs visit healthcare service providers such as a
Primary Care Provider(PCP), secondary care provider, specialist, hospital or pharmacy to receive healthcare services.
Each visit that a member makes to a provider is called an encounter. Encounter(s) filed together for the reimbursement of
the medical expenses for the services rendered by the provider is called Claim.
Claims are either filed on paper or sent electronically via fax or email. The claim is received by the insurance company,
validated for necessary information and then loaded into a database. The claim is then adjudicated (or tested for
authenticity) as per the company’s business rules and policies through the claims adjudication system.
6. A medical
service is
provided to
a member
Mail
A claim for
payment is
submitted
Healthcare Overview
Medical
Service
6
7. A medical
service is
provided to
a member
Mail
A claim for
payment is
submitted
Scan
claim is
submitted
to Health
insurance
companies
Healthcare Overview
Medical
Service
7
8. A medical
service is
provided to
a member
Mail
A claim for
payment is
submitted
Scan Enter
Claim data
is entered
into the
system
Healthcare Overview
Medical
Service
8
8
claim is
submitted
to Health
insurance
companies
9. A medical
service is
provided to
a member
Mail
A claim for
payment is
submitted
Scan Enter Correct
Claim data
errors are
resolved
Healthcare Overview
Medical
Service
9
claim is
submitted
to
Healthcare
insurance
companies
Claim data
is entered
into the
system
10. A medical
service is
provided to
a member
Mail
A claim for
payment is
submitted
Scan Enter Correct
Claim data
errors are
resolved
Discuss
Customer
Service
engages
the
subscriber
or provider
if needed
Healthcare Overview
Medical
Service
10
claim is
submitted
to
Healthcare
insurance
companies
Claim data
is entered
into the
system
14. 14
A member is a person who purchases insurance from (or enrolls with) an insurance company.
He can purchase the insurance coverage for himself and his family (also called his
dependents). This is known as Individual Insurance. In most cases, his employer will pay for
his insurance coverage. In such a case the employer becomes his plan sponsor and the
insurance is known as Group Insurance.
The main advantage with group insurance is the freedom of choice for a member. He is free
to choose any of the services offered by the insurance company. However, he has to pay for
those services. Reduction in this cost to the member is a great advantage with group
insurance. A group has much more bargaining power due to the simple fact that group
insurance is less risky for the insurer.
In case of some large corporations the company itself provides insurance to its employees.
Such groups are known as self-insured groups. They offer a great flexibility to the company in
providing insurance of choice to the employees. However, these companies do not have the
infrastructure to perform as an insurance company. So, they outsource the administrative
part to the insurance companies while retaining the money reimbursement part with
themselves. This way, they are able to achieve a balance between providing desirable
healthcare coverage to their employees without causing administrative overheads.
Member
15. 15
A Provider is that entity which offers actual medical services to the members. A doctor, a pharmacy or hospitals are all referred to
as providers. The providers enter into an agreement (contract) with the insurance company. Under this agreement they provide
medical care at reduced rates to the members, in return they are offered monetary benefits by the insurance company. These
monetary benefits are offered in various forms.
One of the most popular of these forms is a fixed monthly fee (capitation fee). The providers get this fee irrespective of the
number of encounters (a visit by a member to a provider is known as an encounter) they had in that month. While on one hand
capitation ensures a fixed monthly income for the provider, it also restricts his earnings. So, from the provider’s point of view it’s a
choice between a fixed income and a varying income (which may be more, or less, depending on his popularity with the patients).
For insurance company, capitation helps them to forecast their spending, as the total expenditure remains constant irrespective
of the number of members having to seek medical services.
Sometimes, individual providers form a group, which contracts with the insurance company. Such a group is called an IPA or an
individual practice association. Formation of an IPA gives the providers more bargaining powers with the insurance company and
assures them of an increased patient volume. In turn the insurance company is able to offer a range of providers to the members
at a single source, i.e. the IPA.
In general, a group of providers in a designated area are contracted by the insurance company to form a network (a group of
contracted providers within a designated area is said to constitute a network) of providers. The insurance company offers a better
deal to its members for using a provider within this network. The providers themselves have an increased patient volume and
hence offer services at reduced rates. This is one of the most stable models of managed healthcare.
Provider
16. 16
Benefits can be described in two ways -
•The right of a member to receive services from the insurance company as per their mutual agreement, or,
•The major line of coverage provided by the insurance company. The insurance company may provide medical/dental/vision coverage. Then depending on the choice
of coverage the member is said to have medical benefits or dental benefits or vision benefits.
The general agreement between the Insurance Company and the member that details the benefits that can be provided to the plan holders i.e. the member is called a
Plan. While the actual legal document issued by the insurance company to the member, whom sets forth the terms and conditions of this agreement is called a Policy.
Thus, we can say that a plan is the general range of benefits offered by the insurance company. These when customized as per the member’s requirements and put
down on paper as a legal document forms a policy.
In case of Indemnity plans, the members visit a provider and pay him for his services. After that, they file a claim (a request to refund the expenses incurred) with the
insurance company. If the claim is found to be valid, the insurance company pays a part (usually 80%) of the expenses. Though they offer great flexibility to members
in their choice of providers, they are very expensive.
In case of managed care, the insurance company contracts with providers and form a network of such providers. The members pay a fixed monthly fee and need to
choose a provider within the network as their primary care physician or a PCP. The PCP manages their complete healthcare, right from providing services to filing
claims. Due to the control over the choice of provider, the insurance company is able to offer healthcare at reduced rates. The reduced cost of a managed care plan is
the main reason for members preferring them to indemnity plans.
The model of managed care as described above is known as a HMO or a health maintenance organization. It has a major disadvantage that it limits the choice of
providers to a network. Members cannot avail services from a provider not contracted with the insurance company. Members who wish to have a greater flexibility in
the choice of providers have the option of going for other managed care plans POS or point of service plans and PPO or preferred provider organization plans.
POS provides the member with the option of having HMO type coverage at a lower fee, while having the option of Indemnity type coverage at a higher fee. PPO is
also similar to POS with the added advantage that in the HMO type coverage the member is not needed to have a PCP.EPO or exclusive provider organization, a
hybrid of HMO and POS plans, is a recent addition to the stable of managed care plans.
The recent trend has been to go for PPO plans, as it offers the best of both Indemnity and Managed care plans.
Benefits
17. What is a Claim?
A claim is filed by an insurer. It contains the details of the policy, a filled-out claim form and treatment bills, including
those from tests and rehabilitation prescribed by the doctor, the nature of the treatment with diagnosis information and/or
other documentation of medical expenses. A claim has an extensive life process, starting with a provider or subscriber.
This session discusses the basic lifecycle of a claim:
Claim Batching
Claims Processing
Claim Adjudication
Claim
17
Claims are mainly categorized as:-
Medical claims
Dental claims
Pharmacy claims
Vision claims
18. All claims are date stamped and sorted into batches by line of business:
Single page claims
Multi-page claims
In-state
Out-of-state
Single page facility/institutional
Multi-page facility/institutional
Single page miscellaneous
Day in the Life of a Claim
18
19. Before leaving, batches are put through a final process:
Each claim is assigned a document number
The document number will allow retrieval of copy at a later date
The batches are delivered to the claims processing unit
Day in the Life of a Claim
19
20. Batches are received in health insurance companies and assigned to claims
processors by Supervisor.
The processor accesses the batch entry screen and enters all the claims within
the batch
After claims within the batch are entered, it is released to the claims Processing
System
Some claims are received electronically or are optical scanned directly into claims
processing system
Day in the Life of a Claim
20
21. Electronic Error Correction (EEC) suspense processing accesses suspended claims and corrects
errors.
system edits claims for eligibility, benefit availability, and so on
When this is complete, the claim will either pay or reject
An explanation of benefits is sent to the subscriber
If provider is participating, a voucher and check is sent
On completion of claims adjudication, member receives a check for payment of the expenses. The
member is also sent a letter called the explanation of benefits (EOB). EOB gives the details of the
services rendered to him by the providers and the amount of expenses to be borne by the member for
the services he has used. It also gives the amounts applicable to him.
Day in the Life of a Claim
21
22. 22
If the member is enrolled in an Indemnity plan, then things are very simple. He can go to any provider of
his choice. He pays the provider then and there and files a claim with the insurance company. However, it
is necessary that he should have satisfied his deductible for that particular year.
In case of managed care plans, the flow is a bit more complicated. The member first has to visit his PCP.
The PCP will try to provide as many services as he can. But, if a medical condition arises which requires
treatment from a specialist, the PCP will provide a referral to the member. This referral authorizes the
member to seek medical services of a specialist provider. The PCP will also file a claim on behalf of the
member. The member only has to pay fixed copay to both the PCP and the specialist. This is the flow in
case of HMO and EPO plans.
In case of POS and PPO plans, the member can seek services from out of network providers. However,
they will have to meet a deductible before they can avail this facility. Also the concept of coinsurance will
come into picture. In case of PPO plans the member has the added advantage that he does need to have
a PCP for
In-network care.
An Enrolled Member seeks Medical Service
23. Brief discussion on ICD-10 codes
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ICD is defined as International classification of disease. Physicians and other health care providers classify
and code all diagnoses, symptoms and procedures record in conjunction with hospital care in the United
States.
ICD-10 codes differ in length and structure from their predecessors. The increased length and modified
structure will provide more thorough detail about conditions, injuries, or illnesses. In contrast to ICD-9 codes,
the new code set will include specific detail about how an injury occurred, what parts of the body are affected,
and the severity of a condition. This level of specificity means a drastic increase in the number of codes.
Characteristic Diagnosis Codes Procedure Codes
Code Set Name ICD-9-CM ICD-10-CM ICD-9-PCS ICD-10-PCS
Number of Codes 15,000 80,000 4,000 73,000
Number of Characters 3 to 5 3 to 7 3 to 4 7
Type of Characters Numeric Alpha-numeric Numeric Alpha-numeric
Format XXX.XX AXX.XXX X XXX.XX AXX.XXX X
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Brief discussion on ICD-10 codes
Before the ICD-10 codes can be used however, physicians and others in the health care community
had to transition to use of the new version of HIPAA transaction standards known as 5010.
Why ICD-9 to ICD-10
ICD-9 codes are old format. ICD-10 reflects the 10th
revision of codes. The ICD-10 code set
reflects advances in medicine and uses current medical terminology. The code format is expanded,
which means that it has the ability to include greater detail within the code. The greater detail
means that the code can provide more specific information about the diagnosis. The ICD-10 code
set is also more flexible for expansion and including new technologies and diagnoses.
Codes are:
1. Procedure codes
• HCPC codes (Healthcare Common Procedure Coding System)
• CPT codes (Current Procedural Terminology)
2. Diagnosis codes
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ER
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