The document discusses key concepts in the US health insurance system including payers, providers, members, benefit plans, and workflows. It covers payer types like commercial insurers, Medicare, Medicaid, and plan types including PPOs, HMOs, and EPOs. It also summarizes benefits building, enrollment management, network building, and provider contracting processes.
Predicting Denials to Improve the Healthcare Revenue Cycle and Maximize Opera...Health Catalyst
Healthcare financial leaders are constantly brainstorming ways to increase operating margins through better revenue cycle performance. These efforts often lead revenue cycle leaders to denied claims—when a payer doesn’t reimburse a health system for a service rendered. Although denials are a common reason for lost revenue, experts deem nearly 90 percent avoidable.
Effective denials management starts with prevention. Organizations can use revenue cycle performance data, combined with artificial intelligence, to predict areas within each claim’s lifecycle that are likely to result in a denial. With denial insight, health systems can optimize revenue cycle processes to prevent denials and increase operating margins.
The Future of RCM in Healthcare OrganizationsCitiusTech
This document / whitepaper talks about how healthcare technology companies can leverage emerging technologies to derive insights to improve their Revenue Cycle Management process.
Short overview over possibilities and challenges of using artificial intelligence in health care. Presentation from the MultiHelix ThinkTank, May 14 2020.
This document is a major project report submitted by Ranjit Singh for the development of a Hospital Management System using Java programming and a database. It includes an introduction describing the purpose, scope and relevant tools used. An overall description provides goals of the proposed system to manage patient, doctor and room records, billing, and user login details. A feasibility study evaluates the technical, economic, operational and schedule feasibility of the system. The report also includes sections on the entity relationship diagram, database and GUI design, implementation, testing, and conclusion.
Large amounts of heterogeneous medical data have become available in various healthcare organizations (payers, providers, pharmaceuticals). Those data could be an enabling resource for deriving insights for improving care delivery and reducing waste. The enormity and complexity of these datasets present great challenges in analyses and subsequent applications to a practical clinical environment. More details are available here http://dmkd.cs.wayne.edu/TUTORIAL/Healthcare/
The document provides an overview of the complex U.S. healthcare system, including its decentralized market-based structure compared to other countries' centralized systems. It discusses key players like doctors, hospitals, insurers, and governments. It also covers major public programs like Medicare and Medicaid, as well as private insurance concepts like health plans, coding, and reimbursement structures including capitation and fee-for-service.
The document discusses the evolution of healthcare delivery and financing in the U.S., including the passage of the HMO Act of 1973 which established requirements for health maintenance organizations (HMOs). It also covers rising healthcare costs driven by factors such as inflation, new technologies, and medical lawsuits. Other topics include cost shifting practices, basic concepts in health insurance including deductibles and coinsurance, and definitions of key managed care models like HMOs, PPOs, and POS plans.
NPI (National Provider Identifier) Related to US Health Care Industry, Revenu...Jvs Prasad
The National Provider Identifier (NPI) is a 10-digit number that uniquely identifies health care providers. It will replace existing identifiers used in transactions governed by HIPAA. Obtaining an NPI does not guarantee licensure, payment, or enrollment in health plans. The goals of implementing NPIs are to simplify electronic transmission of health information and more efficiently coordinate benefits. All HIPAA-covered health care providers can apply for an NPI online, and must use only NPIs in standard transactions by May 2007. The NPI will not replace Medicare's enrollment or certification processes.
Predicting Denials to Improve the Healthcare Revenue Cycle and Maximize Opera...Health Catalyst
Healthcare financial leaders are constantly brainstorming ways to increase operating margins through better revenue cycle performance. These efforts often lead revenue cycle leaders to denied claims—when a payer doesn’t reimburse a health system for a service rendered. Although denials are a common reason for lost revenue, experts deem nearly 90 percent avoidable.
Effective denials management starts with prevention. Organizations can use revenue cycle performance data, combined with artificial intelligence, to predict areas within each claim’s lifecycle that are likely to result in a denial. With denial insight, health systems can optimize revenue cycle processes to prevent denials and increase operating margins.
The Future of RCM in Healthcare OrganizationsCitiusTech
This document / whitepaper talks about how healthcare technology companies can leverage emerging technologies to derive insights to improve their Revenue Cycle Management process.
Short overview over possibilities and challenges of using artificial intelligence in health care. Presentation from the MultiHelix ThinkTank, May 14 2020.
This document is a major project report submitted by Ranjit Singh for the development of a Hospital Management System using Java programming and a database. It includes an introduction describing the purpose, scope and relevant tools used. An overall description provides goals of the proposed system to manage patient, doctor and room records, billing, and user login details. A feasibility study evaluates the technical, economic, operational and schedule feasibility of the system. The report also includes sections on the entity relationship diagram, database and GUI design, implementation, testing, and conclusion.
Large amounts of heterogeneous medical data have become available in various healthcare organizations (payers, providers, pharmaceuticals). Those data could be an enabling resource for deriving insights for improving care delivery and reducing waste. The enormity and complexity of these datasets present great challenges in analyses and subsequent applications to a practical clinical environment. More details are available here http://dmkd.cs.wayne.edu/TUTORIAL/Healthcare/
The document provides an overview of the complex U.S. healthcare system, including its decentralized market-based structure compared to other countries' centralized systems. It discusses key players like doctors, hospitals, insurers, and governments. It also covers major public programs like Medicare and Medicaid, as well as private insurance concepts like health plans, coding, and reimbursement structures including capitation and fee-for-service.
The document discusses the evolution of healthcare delivery and financing in the U.S., including the passage of the HMO Act of 1973 which established requirements for health maintenance organizations (HMOs). It also covers rising healthcare costs driven by factors such as inflation, new technologies, and medical lawsuits. Other topics include cost shifting practices, basic concepts in health insurance including deductibles and coinsurance, and definitions of key managed care models like HMOs, PPOs, and POS plans.
NPI (National Provider Identifier) Related to US Health Care Industry, Revenu...Jvs Prasad
The National Provider Identifier (NPI) is a 10-digit number that uniquely identifies health care providers. It will replace existing identifiers used in transactions governed by HIPAA. Obtaining an NPI does not guarantee licensure, payment, or enrollment in health plans. The goals of implementing NPIs are to simplify electronic transmission of health information and more efficiently coordinate benefits. All HIPAA-covered health care providers can apply for an NPI online, and must use only NPIs in standard transactions by May 2007. The NPI will not replace Medicare's enrollment or certification processes.
Digital healthcare technologies are transforming healthcare delivery globally. Companies are developing technologies like mobile apps, big data analytics, and smart medical devices to improve patient monitoring and outcomes. These digital innovations extract insights from medical data to enhance healthcare provisioning, reduce costs, and support preventative care and remote patient monitoring. Emerging areas like bioinformatics and medical analytics utilize big data to provide actionable clinical insights.
The Healthcare Revenue Cycle: How to Optimize PerformanceHealth Catalyst
Health systems rely on effective revenue cycle management to follow the patient journey, navigate claims, and ensure the organization collects payment for its services. In today’s complex and fluid healthcare industry, in which revenue cycle management is about much more than billing and collecting payment, traditional revenue cycle approaches can’t meet escalating demands. Additionally, with lost volume due to COVID-19, organizations can’t afford to miss an opportunity for payment.
The contemporary healthcare landscape requires a comprehensive, standardized, and data-driven revenue cycle process. Health systems that leverage data to support revenue cycle management improve their financial outcomes in three significant ways:
1. Reduce denials.
2. Increase collections with propensity-to-pay insight.
3. Improve discharged-not-final-billed efforts.
This document discusses how artificial intelligence is being used in healthcare for more accurate and faster diagnosis of medical conditions. It explains that AI can assist doctors in diagnosis or even make diagnoses independently using machine learning. The technology is being implemented in hospitals using diagnostic AI that can offer suggestions to doctors. While initial costs are high, AI is expected to save billions and greatly increase the efficiency of diagnosis. It predicts that AI will be widely used in healthcare by 2025 to benefit patients through reduced costs, more accessible care, and better outcomes.
This document provides an overview of an e-Hospital project that aims to automate hospital activities. The key points are:
- The project will integrate the hospital management system (HMS) with the government's online registration system portal. This will allow for online patient registration, appointments, billing, staff management, and more.
- The system is being developed as part of India's Digital India initiative to connect hospitals across the country. Patients will be able to use their Aadhaar ID to register online and access services at any government hospital.
- The project manager is responsible for defining the scope, creating schedules, estimating costs, setting goals, managing time and budgets, and overseeing implementation and monitoring.
Using Big Data for Improved Healthcare Operations and AnalyticsPerficient, Inc.
Big Data technologies represent a major shift that is here to stay. Big Data enables the use of all types of data, including unstructured data like clinical notes and medical images, for new insights. Advanced analytics like predictive modeling and text mining will become more prevalent and intelligent with Big Data. Big Data will impact application development and require changes to data management approaches. Technologies like Hadoop, NoSQL databases, and semantic modeling will be important for healthcare Big Data.
Framing Trust in Medical AI: Seminar EurAI ACAIJose M. Juarez
In this tutorial we will introduce the medical Artificial Intelligence field and how to handle the major concerns of doctors to adopt AI-based technologies in daily clinical practice.
The development of trustworthy AI system is multidisciplinary requiring ethical, legal, and technological measures.
This tutorial was first given in the 19th Advanced Course on AI (ACAI) is a specialized course in Artificial Intelligence sponsored by EurAI. The theme of the 2022 ACAI School is Explainable AI.
DESCRIPTION:
During this tutorial, the students will have a general vision of existing initiatives made by the European Union on the ethical and legal framework related to AI in healthcare (ethics guidelines, GDPR, AI , medical devices). The tutorial will overview most popular explainable methods on AI (e.g. LIME, SHAP, saliency maps) highlighting their advantages and drawbacks from the clinician’s perspective. To illustrate the different challenges of medical AI, this tutorial is driven by several examples obtained from the recent literature on the AI and medical fields.
WEBSITE OF THE SEMINAR
https://webs.um.es/jmjuarez/trustAImedicine/
Objectives
*To gain a better understanding of applying AI in healthcare settings.
*To identify principal interdisciplinary factors for a trustworthy AI project according to EU guidelines.
*To be aware of advantages and limitations of current eXplainable AI.
The document describes a proposed hospital management system that aims to digitize and improve upon an existing manual paper-based system. The proposed system would manage key information like patients, doctors, appointments, prescriptions, lab reports, and more in an efficient online manner. It consists of 6 main modules - administration, doctors, patients, reception, laboratories, and appointments. The system would use technologies like HTML, CSS, PHP, JavaScript, Bootstrap and store data in a MySQL database. It is intended to save time and resources over the current manual process.
The document describes TiaTech's virtual health information management system called TiaNuMR. It consists of over 40 modular components that provide a comprehensive and integrated ecosystem for healthcare management. This includes electronic health records, telehealth capabilities, billing, insurance processing, laboratory and radiology systems, and other features. The system aims to simplify interactions between patients and providers while improving efficiency and reducing costs.
This document provides an overview of Medicare, including the different parts of Medicare coverage (Part A, B, C, and D), options for supplemental coverage like Medigap plans and Medicare Advantage plans, eligibility requirements, enrollment periods, and programs that can help cover costs like Medicaid and Medicare Savings Programs. Key details include how Original Medicare works, how Medigap plans can help cover out-of-pocket costs, the types of Medicare Advantage plans available, and that all Medicare Part D prescription drug plans must offer at least a standard level of coverage.
AI is increasingly being used in the healthcare sector to address various challenges. It has applications ranging from early disease detection using medical data mining to aiding drug discovery. While major technology companies like IBM, Google, and Microsoft are actively working on developing AI solutions for healthcare, there are also numerous startups in this space. However, adoption of AI in healthcare is still at an early stage due to challenges like lack of digitization of patient records in some regions and fears around job losses. As more data becomes available and technologies advance, AI is expected to play a transformative role in improving healthcare outcomes and efficiency.
This document provides an overview of hospital management systems and the benefits of web-based systems. It discusses that web-based systems allow for simultaneous access to data from various points and integration of all parties. The document then reviews characteristics of web-based systems like multiple autonomous components and points of control/failure. Benefits of a hospital management web-based system include improved patient care through increased access to records, improved cost control through standardized processes, and increased security of patient information.
The number of startups entering the healthcare AI space has increased in recent years, with over 50 companies raising their first equity rounds since January 2015. Deals to healthcare-focused AI startups went up from less than 20 in 2012 to nearly 70 in 2016.
The document discusses the process of submitting, processing, adjudicating, and paying health insurance claims. It begins by outlining the benefits of electronic claims submission over manual submission, such as lower processing costs and fewer errors. It then provides a seven-step overview of how health insurers typically process electronic claims, including determining eligibility, applying pricing edits, adjudicating the claim, generating explanations of benefits, and sending payment. Finally, it emphasizes the importance of reviewing health insurer contracts and auditing claims to appeal inappropriately paid or denied claims.
The document outlines the workflow for patient visits at Lake Aire's Adult Health and Wellness center. It involves checking in, determining if the patient is new or returning, screening for financial assistance eligibility, taking vitals, the provider exam, check out, and scheduling follow ups. Key steps include financial screening, examining the patient, the provider discussing results and care plan, and completing checkout which may involve billing or setting up a payment plan.
The document describes a major project report submitted by Jagjeet Suryawanshi and Lavkush Patkar for their Bachelor of Technology degree. It includes declarations, certificates of approval, an abstract, acknowledgements, and outlines the various chapters that will be included in the project report such as introduction, analysis, methodology, design and implementation, implementation and testing, user manual, and conclusions. The project is on developing an E-Healthcare system under the guidance of Dr. Umesh Banodha.
Generative AI in Healthcare Market - Copy - Copy.pptxGayatriGadhave1
The document discusses the use of generative AI in healthcare. It defines generative AI as technology that can generate diverse content like images, text, and audio. Generative AI uses neural networks to identify patterns in data and generate new content. It has various applications in healthcare like drug discovery, medical imaging, disease diagnosis, and medical research. The document outlines several use cases of generative AI and factors contributing to its growth in healthcare. It predicts generative AI will continue transforming healthcare by enabling personalized medicine, virtual clinical trials, and a deeper understanding of human health.
Artificial Intelligence (AI) is shaping and reshaping every industry under the sun. The Healthcare industry is not any exception.
In this presentation, I have discussed the basics of AI as well as how it is being used in various branches of the healthcare industry. I presented this topic in my departmental seminar in October 2021 and received appreciation as well as positive feedback in this regard.
Health insurance in the US has evolved from primarily covering catastrophic illness to also covering preventative care and services. There are various types of health insurance plans including HMOs, PPOs, and consumer-driven plans. Government plans like Medicare and Medicaid provide coverage for specific groups. Providers must verify a patient's insurance coverage and submit claims according to the insurer's requirements to receive reimbursement.
The document provides an overview of the roles and responsibilities of a health insurance specialist. It discusses how insurance specialists assist physician practices by gathering patient information, obtaining authorizations, filing claims, and tracking reimbursements. It also outlines the qualifications needed for the role, including skills in medical terminology, coding, insurance regulations, and use of billing software. Additional sections cover topics like common health plans, insurance terminology, the claims process, coding, fee schedules, and communicating with patients about financial matters.
Digital healthcare technologies are transforming healthcare delivery globally. Companies are developing technologies like mobile apps, big data analytics, and smart medical devices to improve patient monitoring and outcomes. These digital innovations extract insights from medical data to enhance healthcare provisioning, reduce costs, and support preventative care and remote patient monitoring. Emerging areas like bioinformatics and medical analytics utilize big data to provide actionable clinical insights.
The Healthcare Revenue Cycle: How to Optimize PerformanceHealth Catalyst
Health systems rely on effective revenue cycle management to follow the patient journey, navigate claims, and ensure the organization collects payment for its services. In today’s complex and fluid healthcare industry, in which revenue cycle management is about much more than billing and collecting payment, traditional revenue cycle approaches can’t meet escalating demands. Additionally, with lost volume due to COVID-19, organizations can’t afford to miss an opportunity for payment.
The contemporary healthcare landscape requires a comprehensive, standardized, and data-driven revenue cycle process. Health systems that leverage data to support revenue cycle management improve their financial outcomes in three significant ways:
1. Reduce denials.
2. Increase collections with propensity-to-pay insight.
3. Improve discharged-not-final-billed efforts.
This document discusses how artificial intelligence is being used in healthcare for more accurate and faster diagnosis of medical conditions. It explains that AI can assist doctors in diagnosis or even make diagnoses independently using machine learning. The technology is being implemented in hospitals using diagnostic AI that can offer suggestions to doctors. While initial costs are high, AI is expected to save billions and greatly increase the efficiency of diagnosis. It predicts that AI will be widely used in healthcare by 2025 to benefit patients through reduced costs, more accessible care, and better outcomes.
This document provides an overview of an e-Hospital project that aims to automate hospital activities. The key points are:
- The project will integrate the hospital management system (HMS) with the government's online registration system portal. This will allow for online patient registration, appointments, billing, staff management, and more.
- The system is being developed as part of India's Digital India initiative to connect hospitals across the country. Patients will be able to use their Aadhaar ID to register online and access services at any government hospital.
- The project manager is responsible for defining the scope, creating schedules, estimating costs, setting goals, managing time and budgets, and overseeing implementation and monitoring.
Using Big Data for Improved Healthcare Operations and AnalyticsPerficient, Inc.
Big Data technologies represent a major shift that is here to stay. Big Data enables the use of all types of data, including unstructured data like clinical notes and medical images, for new insights. Advanced analytics like predictive modeling and text mining will become more prevalent and intelligent with Big Data. Big Data will impact application development and require changes to data management approaches. Technologies like Hadoop, NoSQL databases, and semantic modeling will be important for healthcare Big Data.
Framing Trust in Medical AI: Seminar EurAI ACAIJose M. Juarez
In this tutorial we will introduce the medical Artificial Intelligence field and how to handle the major concerns of doctors to adopt AI-based technologies in daily clinical practice.
The development of trustworthy AI system is multidisciplinary requiring ethical, legal, and technological measures.
This tutorial was first given in the 19th Advanced Course on AI (ACAI) is a specialized course in Artificial Intelligence sponsored by EurAI. The theme of the 2022 ACAI School is Explainable AI.
DESCRIPTION:
During this tutorial, the students will have a general vision of existing initiatives made by the European Union on the ethical and legal framework related to AI in healthcare (ethics guidelines, GDPR, AI , medical devices). The tutorial will overview most popular explainable methods on AI (e.g. LIME, SHAP, saliency maps) highlighting their advantages and drawbacks from the clinician’s perspective. To illustrate the different challenges of medical AI, this tutorial is driven by several examples obtained from the recent literature on the AI and medical fields.
WEBSITE OF THE SEMINAR
https://webs.um.es/jmjuarez/trustAImedicine/
Objectives
*To gain a better understanding of applying AI in healthcare settings.
*To identify principal interdisciplinary factors for a trustworthy AI project according to EU guidelines.
*To be aware of advantages and limitations of current eXplainable AI.
The document describes a proposed hospital management system that aims to digitize and improve upon an existing manual paper-based system. The proposed system would manage key information like patients, doctors, appointments, prescriptions, lab reports, and more in an efficient online manner. It consists of 6 main modules - administration, doctors, patients, reception, laboratories, and appointments. The system would use technologies like HTML, CSS, PHP, JavaScript, Bootstrap and store data in a MySQL database. It is intended to save time and resources over the current manual process.
The document describes TiaTech's virtual health information management system called TiaNuMR. It consists of over 40 modular components that provide a comprehensive and integrated ecosystem for healthcare management. This includes electronic health records, telehealth capabilities, billing, insurance processing, laboratory and radiology systems, and other features. The system aims to simplify interactions between patients and providers while improving efficiency and reducing costs.
This document provides an overview of Medicare, including the different parts of Medicare coverage (Part A, B, C, and D), options for supplemental coverage like Medigap plans and Medicare Advantage plans, eligibility requirements, enrollment periods, and programs that can help cover costs like Medicaid and Medicare Savings Programs. Key details include how Original Medicare works, how Medigap plans can help cover out-of-pocket costs, the types of Medicare Advantage plans available, and that all Medicare Part D prescription drug plans must offer at least a standard level of coverage.
AI is increasingly being used in the healthcare sector to address various challenges. It has applications ranging from early disease detection using medical data mining to aiding drug discovery. While major technology companies like IBM, Google, and Microsoft are actively working on developing AI solutions for healthcare, there are also numerous startups in this space. However, adoption of AI in healthcare is still at an early stage due to challenges like lack of digitization of patient records in some regions and fears around job losses. As more data becomes available and technologies advance, AI is expected to play a transformative role in improving healthcare outcomes and efficiency.
This document provides an overview of hospital management systems and the benefits of web-based systems. It discusses that web-based systems allow for simultaneous access to data from various points and integration of all parties. The document then reviews characteristics of web-based systems like multiple autonomous components and points of control/failure. Benefits of a hospital management web-based system include improved patient care through increased access to records, improved cost control through standardized processes, and increased security of patient information.
The number of startups entering the healthcare AI space has increased in recent years, with over 50 companies raising their first equity rounds since January 2015. Deals to healthcare-focused AI startups went up from less than 20 in 2012 to nearly 70 in 2016.
The document discusses the process of submitting, processing, adjudicating, and paying health insurance claims. It begins by outlining the benefits of electronic claims submission over manual submission, such as lower processing costs and fewer errors. It then provides a seven-step overview of how health insurers typically process electronic claims, including determining eligibility, applying pricing edits, adjudicating the claim, generating explanations of benefits, and sending payment. Finally, it emphasizes the importance of reviewing health insurer contracts and auditing claims to appeal inappropriately paid or denied claims.
The document outlines the workflow for patient visits at Lake Aire's Adult Health and Wellness center. It involves checking in, determining if the patient is new or returning, screening for financial assistance eligibility, taking vitals, the provider exam, check out, and scheduling follow ups. Key steps include financial screening, examining the patient, the provider discussing results and care plan, and completing checkout which may involve billing or setting up a payment plan.
The document describes a major project report submitted by Jagjeet Suryawanshi and Lavkush Patkar for their Bachelor of Technology degree. It includes declarations, certificates of approval, an abstract, acknowledgements, and outlines the various chapters that will be included in the project report such as introduction, analysis, methodology, design and implementation, implementation and testing, user manual, and conclusions. The project is on developing an E-Healthcare system under the guidance of Dr. Umesh Banodha.
Generative AI in Healthcare Market - Copy - Copy.pptxGayatriGadhave1
The document discusses the use of generative AI in healthcare. It defines generative AI as technology that can generate diverse content like images, text, and audio. Generative AI uses neural networks to identify patterns in data and generate new content. It has various applications in healthcare like drug discovery, medical imaging, disease diagnosis, and medical research. The document outlines several use cases of generative AI and factors contributing to its growth in healthcare. It predicts generative AI will continue transforming healthcare by enabling personalized medicine, virtual clinical trials, and a deeper understanding of human health.
Artificial Intelligence (AI) is shaping and reshaping every industry under the sun. The Healthcare industry is not any exception.
In this presentation, I have discussed the basics of AI as well as how it is being used in various branches of the healthcare industry. I presented this topic in my departmental seminar in October 2021 and received appreciation as well as positive feedback in this regard.
Health insurance in the US has evolved from primarily covering catastrophic illness to also covering preventative care and services. There are various types of health insurance plans including HMOs, PPOs, and consumer-driven plans. Government plans like Medicare and Medicaid provide coverage for specific groups. Providers must verify a patient's insurance coverage and submit claims according to the insurer's requirements to receive reimbursement.
The document provides an overview of the roles and responsibilities of a health insurance specialist. It discusses how insurance specialists assist physician practices by gathering patient information, obtaining authorizations, filing claims, and tracking reimbursements. It also outlines the qualifications needed for the role, including skills in medical terminology, coding, insurance regulations, and use of billing software. Additional sections cover topics like common health plans, insurance terminology, the claims process, coding, fee schedules, and communicating with patients about financial matters.
This document provides an overview of Medicare including its different parts (A, B, C, and D). It discusses eligibility and enrollment, what is covered under each part, premiums and deductibles, penalties for late enrollment, and provides a quiz to test understanding. Key points include that Part A covers hospital, skilled nursing facility, home health, and hospice care while Part B covers doctor services and outpatient care. Part C is Medicare Advantage which provides managed care options. Part D is prescription drug coverage offered through private insurers.
This document provides an overview and training on MVP's Medicare Advantage employer group product. It begins with instructions for the 30 minute online training, which includes a required knowledge check at the end with a minimum passing score of 85%. The training then reviews the four parts of Medicare including eligibility and benefits of Parts A, B, C, and D. It provides details on Medicare Advantage plans under Part C, their benefits and premiums. It also explains key concepts related to prescription drug coverage under Part D such as different plan types, the standard benefit structure, cost sharing approaches, and the stages of the Part D benefit.
2023-employer-group-product-certification.pdfMVP Health Care
This document provides an overview and training on MVP's Medicare Advantage employer group product. It begins with instructions for the 30 minute online training, which includes a required knowledge check at the end with a minimum passing score of 85%. The training then reviews the four parts of Medicare including eligibility and benefits of Parts A, B, C, and D. It provides details on Medicare Advantage plans under Part C, their benefits and premiums. It also explains key concepts related to prescription drug coverage under Part D such as different plan types, the standard benefit structure, cost sharing approaches, and the stages of the Part D benefit.
This document summarizes insurance eligibility, coverage, and benefits for residential behavioral health settings. It finds that 84% of admissions in 2009 were insurance-based. It describes differences between in-network and out-of-network coverage for major insurance providers, as well as plan types like PPO, HMO, EPO, and POS. The document also outlines eligibility criteria, covered benefits, and patient financial responsibility. Finally, it reviews behavioral health levels of care and pre-admission screening information required.
Medicare Bad Debt Checklist and Recent ClarificationsPYA, P.C.
PYA Senior Consultant Holly Bizic presented “Medicare Bad Debt Checklist and Recent Clarifications.” The presentation reviews:
Key facts and expectations.
Progression of Medicare bad debt policy.
Recommendations for compiling and defending bad debt listings.
Audit and desk review clarifications.
Benchmarking.
This document provides an overview of the four parts of Medicare (Parts A, B, C, and D) and summarizes their key features. It explains that Part A covers hospital insurance, Part B covers medical insurance, Part C is the Medicare Advantage program offered by private insurers, and Part D is the prescription drug plan. It provides details on eligibility, covered benefits, premiums, and enrollment periods for each part. It also summarizes other Medicare options like Medicare Supplement plans, Medicare-Medicaid plans, and Medicare beneficiary protections.
This webinar continues the COVID-19 Insights webinar series. Topics include the loans and grants being offered by the government, how they differ, and how they may benefit your practice, including SBA Loans and Grants, HHS Grants, Medicare Advance/Accelerated Payments, and Telehealth Funding. The webinar also goes over the CareOptimize technology developed to assist with streamlining COVID-19 monitoring and reporting.
This document provides training materials on insurance fundamentals and health plans. It defines key insurance terminology like HMOs, PPOs, and POS plans. It explains how to find health plan contract summaries online and what information they contain. Common insurance terms are defined, including different types of insurance payors, plans, and individual vs. group coverage. The document compares different types of managed care plans and their key features. It also summarizes Medicare including the different parts and supplemental plans. Medicaid eligibility and managed care options are overviewed. Important healthcare acronyms are listed. Case scenarios are provided to demonstrate how to handle different patient insurance situations.
high value care to reduce waste in health caremukeshkakkar
This document discusses health care costs and payment models. It defines different types of health care costs including charges, reimbursements, and out-of-pocket costs. It describes how traditional payment models like fee-for-service can promote cost variation and lack transparency. It also discusses recent value-based reforms like accountable care organizations (ACOs) and pay for performance models that aim to improve quality and reduce costs. The document provides examples of estimating out-of-pocket costs and explores how insurance status impacts clinical recommendations and adherence.
This document provides an overview of Medicare including its four parts (Part A, B, C, and D) and eligibility. It discusses the Affordable Care Act changes to Medicare including closing the prescription drug coverage donut hole, extending the financial health of Medicare, and improving preventive services coverage. It also covers becoming a Medicare provider or supplier, including enrollment steps and reimbursement as a participating or nonparticipating provider.
The document provides an overview of medical billing and coding concepts and processes. It covers key topics such as the importance of medical billing, the billing process, common terminology and acronyms, and a simplified diagram of the billing and coding process. Key aspects of the billing process include coding patient diagnoses and treatments, submitting claims to insurance companies, following up on rejected or denied claims, and collecting payments from insurance providers and patients.
Upon completion of this discussion forum, participants will:
- Learn about governmental programs and eligibility criteria for accessing care
- Gain tools to reduce and manage outstanding medical costs
- Better understand benefits of the ACA relative to cancer care
- Become informed of laws protecting their right to health coverage
- Understand the Social Security Disability approval process
Population Health Management: Enabling Accountable Care in Collaborative Prov...Salus One Ed
This document provides the reader information about population health management (PMH), how it relates to incentive payments for healthcare providers and their health insurance partners (commercial and government). See details about required transformation of care delivery methods, typical accountable care payment models, how to achieve incentives, partnerships between state government (public health) and community shared services needs and necessary technology and data to achieve it.
On Tuesday, April 9 from 2:00 p.m. - 3:00 p.m. EDT the Medicare Advantage Value-Based Insurance Design Model team provided an overview of the model’s main goals and guiding principles, provided a brief review of Medicare Advantage and the Medicare Hospice Benefit, introduced the key model design considerations, and provided a general timeline for the coming months.
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CMS Innovation Center
http://innovation.cms.gov
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There are several methods of financing senior care in the US. Medicaid is the primary source of financing for nursing home care. Medicare covers some costs for seniors and those with disabilities, including limited nursing home coverage after a hospital stay. Private pay rates are set through competition and tend to be higher to cover extra amenities. Fraud and abuse are prosecuted through criminal penalties like fines and jail time. Whistleblowers can also report fraud under qui tam laws and receive a share of monetary recoveries.
Medicare 101 provides an overview of Medicare including who is eligible, how to enroll, and the different parts of Medicare coverage. There are four main parts of Medicare: Part A covers hospital insurance; Part B covers medical insurance; Part C are Medicare Advantage plans managed by private insurers that combine Parts A, B, and sometimes D; and Part D is prescription drug coverage. Premiums and out-of-pocket costs vary depending on income and type of coverage selected. The document reviews costs and options in detail to help people understand Medicare.
MA Appeals Overturn 75% Of Claims Denialsbrennaljan
The name of the company that made the redetermination (the company that handled the Medicare claim in Level 1). You can find this information on the Medicare Summary Notice or the redetermination notice.
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Sectional dentures for microstomia patients.pptxSatvikaPrasad
Microstomia, characterized by an abnormally small oral aperture, presents significant challenges in prosthodontic treatment, including limited access for examination, difficulties in impression making, and challenges with prosthesis insertion and removal. To manage these issues, customized impression techniques using sectional trays and elastomeric materials are employed. Prostheses may be designed in segments or with flexible materials to facilitate handling. Minimally invasive procedures and the use of digital technologies can enhance patient comfort. Education and training for patients on prosthesis care and maintenance are crucial for compliance. Regular follow-up and a multidisciplinary approach, involving collaboration with other specialists, ensure comprehensive care and improved quality of life for microstomia patients.
Health Tech Market Intelligence Prelim Questions -Gokul Rangarajan
The Ultimate Guide to Setting up Market Research in Health Tech part -1
How to effectively start market research in the health tech industry by defining objectives, crafting problem statements, selecting methods, identifying data collection sources, and setting clear timelines. This guide covers all the preliminary steps needed to lay a strong foundation for your research.
This lays foundation of scoping research project what are the
Before embarking on a research project, especially one aimed at scoping and defining parameters like the one described for health tech IT, several crucial considerations should be addressed. Here’s a comprehensive guide covering key aspects to ensure a well-structured and successful research initiative:
1. Define Research Objectives and Scope
Clear Objectives: Define specific goals such as understanding market needs, identifying new opportunities, assessing risks, or refining pricing strategies.
Scope Definition: Clearly outline the boundaries of the research in terms of geographical focus, target demographics (e.g., age, socio-economic status), and industry sectors (e.g., healthcare IT).
3. Review Existing Literature and Resources
Literature Review: Conduct a thorough review of existing research, market reports, and relevant literature to build foundational knowledge.
Gap Analysis: Identify gaps in existing knowledge or areas where further exploration is needed.
4. Select Research Methodology and Tools
Methodological Approach: Choose appropriate research methods such as surveys, interviews, focus groups, or data analytics.
Tools and Resources: Select tools like Google Forms for surveys, analytics platforms (e.g., SimilarWeb, Statista), and expert consultations.
5. Ethical Considerations and Compliance
Ethical Approval: Ensure compliance with ethical guidelines for research involving human subjects.
Data Privacy: Implement measures to protect participant confidentiality and adhere to data protection regulations (e.g., GDPR, HIPAA).
6. Budget and Resource Allocation
Resource Planning: Allocate resources including time, budget, and personnel required for each phase of the research.
Contingency Planning: Anticipate and plan for unforeseen challenges or adjustments to the research plan.
7. Develop Research Instruments
Survey Design: Create well-structured surveys using tools like Google Forms to gather quantitative data.
Interview and Focus Group Guides: Prepare detailed scripts and discussion points for qualitative data collection.
8. Sampling Strategy
Sampling Design: Define the sampling frame, size, and method (e.g., random sampling, stratified sampling) to ensure representation of target demographics.
Participant Recruitment: Plan recruitment strategies to reach and engage the intended participant groups effectively.
9. Data Collection and Analysis Plan
Data Collection: Implement methods for data gathering, ensuring consistency and validity.
Analysis Techniques: Decide on analytical approaches (e.g., statistical
India Home Healthcare Market: Driving Forces and Disruptive Trends [2029]Kumar Satyam
According to the TechSci Research report titled "India Home Healthcare Market - By Region, Competition, Forecast and Opportunities, 2029," the India home healthcare market is anticipated to grow at an impressive rate during the forecast period. This growth can be attributed to several factors, including the rising demand for managing health issues such as chronic diseases, post-operative care, elderly care, palliative care, and mental health. The growing preference for personalized healthcare among people is also a significant driver. Additionally, rapid advancements in science and technology, increasing healthcare costs, changes in food laws affecting label and product claims, a burgeoning aging population, and a rising interest in attaining wellness through diet are expected to escalate the growth of the India home healthcare market in the coming years.
Browse over XX market data Figures spread through 70 Pages and an in-depth TOC on "India Home Healthcare Market”
https://www.techsciresearch.com/report/india-home-healthcare-market/15508.html
Hypertension and it's role of physiotherapy in it.Vishal kr Thakur
This particular slides consist of- what is hypertension,what are it's causes and it's effect on body, risk factors, symptoms,complications, diagnosis and role of physiotherapy in it.
This slide is very helpful for physiotherapy students and also for other medical and healthcare students.
Here is summary of hypertension -
Hypertension, also known as high blood pressure, is a serious medical condition that occurs when blood pressure in the body's arteries is consistently too high. Blood pressure is the force of blood pushing against the walls of blood vessels as the heart pumps it. Hypertension can increase the risk of heart disease, brain disease, kidney disease, and premature death.
CHAPTER 1 SEMESTER V COMMUNICATION TECHNIQUES FOR CHILDREN.pdfSachin Sharma
Here are some key objectives of communication with children:
Build Trust and Security:
Establish a safe and supportive environment where children feel comfortable expressing themselves.
Encourage Expression:
Enable children to articulate their thoughts, feelings, and experiences.
Promote Emotional Understanding:
Help children identify and understand their own emotions and the emotions of others.
Enhance Listening Skills:
Develop children’s ability to listen attentively and respond appropriately.
Foster Positive Relationships:
Strengthen the bond between children and caregivers, peers, and other adults.
Support Learning and Development:
Aid cognitive and language development through engaging and meaningful conversations.
Teach Social Skills:
Encourage polite, respectful, and empathetic interactions with others.
Resolve Conflicts:
Provide tools and guidance for children to handle disagreements constructively.
Encourage Independence:
Support children in making decisions and solving problems on their own.
Provide Reassurance and Comfort:
Offer comfort and understanding during times of distress or uncertainty.
Reinforce Positive Behavior:
Acknowledge and encourage positive actions and behaviors.
Guide and Educate:
Offer clear instructions and explanations to help children understand expectations and learn new concepts.
By focusing on these objectives, communication with children can be both effective and nurturing, supporting their overall growth and well-being.
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - ...rightmanforbloodline
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - 34.
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - 34.
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - 34.
Fit to Fly PCR Covid Testing at our Clinic Near YouNX Healthcare
A Fit-to-Fly PCR Test is a crucial service for travelers needing to meet the entry requirements of various countries or airlines. This test involves a polymerase chain reaction (PCR) test for COVID-19, which is considered the gold standard for detecting active infections. At our travel clinic in Leeds, we offer fast and reliable Fit to Fly PCR testing, providing you with an official certificate verifying your negative COVID-19 status. Our process is designed for convenience and accuracy, with quick turnaround times to ensure you receive your results and certificate in time for your departure. Trust our professional and experienced medical team to help you travel safely and compliantly, giving you peace of mind for your journey.www.nxhealthcare.co.uk
This particular slides consist of- what is Pneumothorax,what are it's causes and it's effect on body, risk factors, symptoms,complications, diagnosis and role of physiotherapy in it.
This slide is very helpful for physiotherapy students and also for other medical and healthcare students.
Here is a summary of Pneumothorax:
Pneumothorax, also known as a collapsed lung, is a condition that occurs when air leaks into the space between the lung and chest wall. This air buildup puts pressure on the lung, preventing it from expanding fully when you breathe. A pneumothorax can cause a complete or partial collapse of the lung.
Mental Health and well-being Presentation. Exploring innovative approaches and strategies for enhancing mental well-being. Discover cutting-edge research, effective strategies, and practical methods for fostering mental well-being.
The Ultimate Guide in Setting Up Market Research System in Health-TechGokul Rangarajan
How to effectively start market research in the health tech industry by defining objectives, crafting problem statements, selecting methods, identifying data collection sources, and setting clear timelines. This guide covers all the preliminary steps needed to lay a strong foundation for your research.
"Market Research it too text-booky, I am in the market for a decade, I am living research book" this is what the founder I met on the event claimed, few of my colleagues rolled their eyes. Its true that one cannot over look the real life experience, but one cannot out beat structured gold mine of market research.
Many 0 to 1 startup founders often overlook market research, but this critical step can make or break a venture, especially in health tech.
But Why do they skip it?
Limited resources—time, money, and manpower—are common culprits.
"In fact, a survey by CB Insights found that 42% of startups fail due to no market need, which is like building a spaceship to Mars only to realise you forgot the fuel."
Sudharsan Srinivasan
Operational Partner Pitchworks VC Studio
Overconfidence in their product’s success leads founders to assume it will naturally find its market, especially in health tech where patient needs, entire system issues and regulatory requirements are as complex as trying to perform brain surgery with a butter knife. Additionally, the pressure to launch quickly and the belief in their own intuition further contribute to this oversight. Yet, thorough market research in health tech could be the key to transforming a startup's vision into a life-saving reality, instead of a medical mishap waiting to happen.
Example of Market Research working
Innovaccer, founded by Abhinav Shashank in 2014, focuses on improving healthcare delivery through data-driven insights and interoperability solutions. Before launching their platform, Innovaccer conducted extensive market research to understand the challenges faced by healthcare organizations and the potential for innovation in healthcare IT.
Identifying Pain Points: Innovaccer surveyed healthcare providers to understand their difficulties with data integration, care coordination, and patient engagement. They found widespread frustration with siloed systems and inefficient workflows.
Competitive Analysis: Analyzed competitors offering similar solutions in healthcare analytics and interoperability. Identified gaps in comprehensive data aggregation, real-time analytics, and actionable insights.
Regulatory Compliance: Ensured their platform complied with HIPAA and other healthcare data privacy regulations. This compliance was crucial to gaining trust from healthcare providers wary of data security issues.
Customer Validation: Conducted pilot programs with several healthcare organizations to validate the platform's effectiveness in improving care outcomes and operational efficiency. Gathered feedback to refine features and user interface.
This particular slides consist of- what is hypotension,what are it's causes and it's effect on body, risk factors, symptoms,complications, diagnosis and role of physiotherapy in it.
This slide is very helpful for physiotherapy students and also for other medical and healthcare students.
Here is the summary of hypotension:
Hypotension, or low blood pressure, is when the pressure of blood circulating in the body is lower than normal or expected. It's only a problem if it negatively impacts the body and causes symptoms. Normal blood pressure is usually between 90/60 mmHg and 120/80 mmHg, but pressures below 90/60 are generally considered hypotensive.
VEDANTA AIR AMBULANCE SERVICES IN REWA AT A COST-EFFECTIVE PRICE.pdfVedanta A
Air Ambulance Services In Rewa works in close coordination with ground-based emergency services, including local Emergency Medical Services, fire departments, and law enforcement agencies.
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At Malayali Kerala Spa Ajman, Full Service includes individualized care for every client. We specifically design each massage session for the individual needs of the client. Our therapists are always willing to adjust the treatments based on the client's instruction and feedback. This guarantees that every client receives the treatment they expect.
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Healthcare business analysis concepts
1. US Health Insurance Concepts
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2. US Health care Segments
Payers
Members
Providers
Benefit Plans
Benefit
Products
Benefit
Services
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3. 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)
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4. 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
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5. 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
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6. 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.
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7. 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.
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8. 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.
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9. 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
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10. 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.
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11. 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).
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12. 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
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13. 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
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14. 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
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15. 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.
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16. 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)
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17. 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.
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18. 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..)
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19. 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
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20. 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:
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21. 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:
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22. 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
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23. 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
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24. 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.
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25. 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
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26. 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.
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27. 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.
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28. 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
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29. 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.
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30. 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:
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31. 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.
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32. 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
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33. 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.
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34. 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.
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35. 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)
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36. Provider - Introduction
Provider Contracting Networking Credentialing
Health Care
Services
Claims and
Correspondence
Legal and HIPAA
adherence
Provider Workflow
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37. Provider - Introduction
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
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38. Provider - Introduction
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
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39. Provider - Introduction
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
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40. Provider - Introduction
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.
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41. Provider - Introduction
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
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42. 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
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43. 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.
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44. 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.
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45. Provider - Introduction to EMR / EHR
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..
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46. Provider - Introduction to EMR / EHR
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.
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47. Provider - Introduction to EMR / EHR
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
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48. Provider - Introduction to EMR / EHR
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
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49. Integrated Systems - Introduction
Need for Integrated systems
Doctors need to be connected with each other
– especially during transfer of care
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50. Integrated Systems - Introduction
Need for Integrated systems
Doctors need to be connected with pharmacists
– reduce harmful errors
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51. Integrated Systems - Introduction
Need for Integrated systems
Hospitals need to be connected with each other
– Especially for medical records transfer
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52. Integrated Systems - Introduction
Need for Integrated systems
Laboratories need to be connected to
the patient’s electronic health record
Doctors need to be connected to the
patient’s personal health record
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53. Integrated Systems - Introduction
Health Information Exchange types
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54. 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.
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55. 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
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56. 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 .
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57. 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
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58. 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
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59. 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.
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60. 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
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61. Provider - Medical Coding
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.
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62. Provider - Medical Coding
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).
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63. Provider - Medical Coding
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.
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64. Provider - Medical Coding
ICD 10 - FACTS
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65. 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
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66. Provider - Claim Submission - Form types
CMS 1500 EXAMPLE
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67. UB 04 EXAMPLE
Provider - Claim Submission - Form types
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68. 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
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69. 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.
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70. 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
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71. 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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