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HEALTH INSURANCE DOMAIN
BASICS
Facilitator: Bharath
Main Entities
Healthcare
Provider/
Doctor/
Hospital/
Facility
Member/Subscriber Group
Health
insurance
Provider/
Carrier
Federal and State
governments
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Basic terminology
Health Insurance - A contract that requires your health insurer to pay some or all of your health care costs in exchange for a Premium
Health insurance provider - the health insurance company whose plan pays to help cover the cost of your care. Also called Payer or Carrier
Healthcare provider - Any person (doctor or nurse) or institution (hospital, clinic, or laboratory) that provides medical care
Preferred Provider - A provider who has a contract with your health insurer or plan to provide services to you at a discount
Facility - hospital setting
Member - A person who is enrolled in a health plan (also called an enrollee or subscriber)
Group - Employer, group insurance
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Basic terminology
Insurance plan - plan selected by the member or group for coverage, based on the premium and benefits
Premium - the amount a plan member or employer pays each month in exchange for insurance coverage
Effective date - the date on which a policyholder's coverage begins
Benefits - specific areas of cover that offer protection against financial loss or damage
Claim - a request by a plan member's health care provider, for the insurance company to pay for medical services
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Basic terminology
Coinsurance: An arrangement under which the member pays a fixed percentage of the cost of medical care after the deductible has been paid. For example, an insurance company might pay 80 percent of the allowable charge, with the member responsible for the remaining 20 percent; the 20 percent amount is then referred to as the coinsurance amount
Copayment: One of the ways the member shares medical costs. For example, a flat fee for certain medical expenses (e.g., $10 for every visit to the doctor), while your insurance company pays the rest
Deductible: The amount of eligible expenses a member must pay each calendar year (or contract year) before the insurance company will make a payment for eligible benefits. Usually applies to the out-of-network services, but may apply to in-network services for certain products
Allowed amount: Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If the provider charges more than the allowed amount, the member may have to pay the difference
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Types of health insurance
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Indemnity plans – These major medical plans typically have a deductible (the amount you pay before the insurance company begins paying benefits). After your covered expenses exceed the deductible amount, benefits usually are paid as a percentage of actual expenses, often 80 percent. These plans usually provide the most flexibility in choosing where to receive care.
Preferred Provider Organization (PPO) plans – In these major medical plans, the insurance company enters into contracts with selected hospitals and doctors to furnish services at a discounted rate. As a member of a PPO, you may be able to seek care from a doctor or hospital that is not a preferred provider, but you will probably have to pay a higher deductible or co-payment.
Health Maintenance Organization (HMO) plans – These major medical plans usually make you choose a primary care physician (PCP) from a list of network providers. Your PCP is responsible for managing all of your healthcare. If you need care from any network provider other than your PCP, you may have to get a referral from your PCP to see that provider. You must receive care from a network provider in order to have your claim paid through the HMO. Treatment received outside the network is usually not covered, or covered at a significantly reduced level.
Point of Service (POS) plans – These major medical plans are a hybrid of the PPO and HMO models. They are more flexible than HMOs, but do require you to select a primary care physician (PCP). Like a PPO, you can go to an out-of-network provider and pay more of the cost. However, if the PCP refers you to an out-of-network doctor, the health plan will pay the cost.
Claims processing – steps
A member with valid health insurance visits an in-network healthcare provider for a doctor service
The healthcare provider renders a service
The healthcare provider submits a claim to health insurance provider
The health insurance provider processes the claim
If the member has a financial responsibility (other than an office visit co-pay), the member will receive and Explanation of Benefits (EOBs) detailing what the health insurance provider has paid. The member may sign up to receive your EOB electronically
The healthcare provider will send a bill to the member if a balance needs to be paid
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Explanation of benefits (EOBs)
An explanation of benefits (commonly referred to as an EOB form) is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf
An EOB typically describes:
the payee, the payer and the patient
the service performed
the date of the service,
the description and/or insurer's code for the service,
the name of the person or place that provided the service, and
the name of the patient
the doctor's fee, and what the insurer allows—the amount initially claimed by the doctor or hospital, minus any reductions applied by the insurer
the amount the patient is responsible for
adjustment reasons, adjustment codes
EOB documents are protected health information. Electronic EOB documents are called edit 835 5010 files
There normally also will be at least a brief explanation of any claims that were denied, along with a point to start an appeal
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Final statuses attached to a
claim
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Finalized
Paid
Denied
Revised – adjudication information has been
changed
Pending – claims put on hold for more
information or claims in the process of
adjudication in the system
Claims pricing based on DRG
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DRG – Diagnosis Related Grouping
DRG is a classification based on clinical factors and utilization of resources
DRG pricing is used only for inpatient admissions. Other hospital visits use different pricing methods
DRG pricing is a fixed payment methodology based on two primary factors:
Negotiated rates with the facility (based on a patient's coverage) Every hospital negotiates its own rates with a payer, known as Standard Base
Rate (SBR). These rates are based on the hospital's patient mix, the size of the facility, and the hospital's average charges for treating specific conditions.
Normal resource consumption for the patient's case Normal resource consumption is the average amount of resources used to
treat any given condition. Resources include anything that hospitals use to treat and care for a patient - food, band-aids, medication, x-rays, surgery, nurses time and anything else required.
Related claims eligible for DRG pricing are grouped together and paid in lump sum amount
Appeals
If your health insurer refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed either internally or by a third party
You can ask that your insurance company reconsider its decision. Insurers have to tell you why they’ve denied your claim or ended your coverage. And they have to let you know how you can dispute their decisions
There are two ways to appeal a health plan decision:
Internal appeal: If your claim is denied or your health insurance coverage cancelled, you have the right to an internal appeal. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process
External review: You have the right to take your appeal to an independent third party for review. This is called external review. External review means that the insurance company no longer gets the final say over whether to pay a claim
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Eligibility & Benefits
Patient eligibility and benefits should be verified prior to every scheduled appointment
Eligibility and benefit quotes include membership verification, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts
It’s strongly recommended that providers ask to see the member’s ID card for current information and photo ID in order to guard against medical identity theft. When services may not be covered, members should be notified that they may be billed directly
Generally members and Providers have access to the following info, online or through telephone:
Patient/Subscriber information
Group Number
Group Name
Plan/Product
Current Effective Dates
Copayment*
Deductible (original and remaining amounts)
Out-of-pocket (original and remaining amounts)
Coinsurance
Limitations/Maximums*
Preauthorization indicators and contacts
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(Prior/Pre) Authorization
process A prior authorization is an extra step that some insurance companies require before
they decide if they want to pay for the doctor services
Some medical procedures and drugs need prior authorization from the Insurance providers
During this process, the insurance provider may request and review medical records, test results and other information so that they understand what services are being performed, and are able to make an informed decision
It’ll be determined if the requested service(s) are medically necessary and identified as covered services under the terms of your health insurance plan based on the information available
Typically notified either in writing, or via telephone within two business days of receiving all necessary documentation. In addition, the member portal of our website gives the status of your authorization online
Emergencies do not need prior authorization
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EDI transaction sets in
healthcare EDI – Electronic Data Interchange
HIPAA mandates EDI standards
As of March 31, 2012, healthcare providers must be compliant with version 5010 of the HIPAA EDI standards. The earlier version was 4010
HIPAA - Health Insurance Portability and Accountability Act
Enacted in 1996
Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs
Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers
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EDI transaction sets in
healthcare
The following are the common EDI transaction
sets in healthcare:
T-Set: 270 - Eligibility, Coverage or Benefit Inquiry
T-Set: 271 - Eligibility, Coverage or Benefit
Information
T-Set: 834 - Benefit Enrollment and Maintenance
T-Set: 835 - Health Care Claim Payment/Advice
T-Set: 837 - Health Care Claim
T-Set: 276 - Health Care Claim Status Request
T-Set: 277 - Health Care Claim Status Notification 12/18/2014
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T-Set: 270 - Eligibility, Coverage or
Benefit Inquiry
The EDI 270 Health Care Eligibility/Benefit Inquiry transaction set is used to request information from a healthcare insurance company about a policy’s coverages, typically in relation to a particular plan subscriber
This transaction is typically sent by healthcare service providers, such as hospitals or medical facilities, and sent to insurance companies, government agencies like Medicare or Medicaid, or other organizations that would have information about a given policy
The 270 document typically includes the following:
Details of the sender of the inquiry (name and contact information of the information receiver)
Name of the recipient of the inquiry (the information source)
Details of the plan subscriber about to the inquiry is referring
Description of eligibility or benefit information requested
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T-Set: 271 - Eligibility, Coverage or
Benefit Information
The EDI 271 Health Care Eligibility/Benefit Response transaction set is used to provide information about healthcare policy coverages relative to a specific subscriber or the subscriber’s dependent seeking medical services. It is sent in response to a 270 inquiry transaction
This transaction is typically sent by insurance companies, government agencies like Medicare or Medicaid, or other organizations that would have information about a given policy. It is sent to healthcare service providers, such as hospitals or medical clinics that inquire to ascertain whether and to what extent a patient is covered for certain services
The 271 document typically includes the following:
Details of the sender of the inquiry (name and contact information of the information receiver)
Name of the recipient of the inquiry (the information source)
Details of the plan subscriber about to the inquiry is referring
Description of eligibility or benefit information requested
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T-Set: 834 - Benefit Enrollment and
Maintenance The EDI 834 transaction set represents a Benefit Enrollment and Maintenance document. It is
used by employers, as well as unions, government agencies or insurance agencies, to enrollmembers in a healthcare benefit plan. The 834 has been specified by HIPAA 5010 standards for the electronic exchange of member enrollment information, including benefits, plan subscription and employee demographic information
The 834 transaction may be used for any of the following functions relative to health plans:
New enrollments
Changes in a member’s enrollment
Reinstatement of a member’s enrollment
Disenrollment of members (i.e., termination of plan membership)
The information is submitted, typically by the employer, to healthcare payer organizations who are responsible for payment of health claims and administering insurance and/or benefits. This may include insurance companies, healthcare professional organizations such as HMOs or PPOs, government agencies such as Medicare and Medicaid
A typical 834 document may include the following information:
Subscriber name and identification
Plan network identification
Subscriber eligibility and/or benefit information
Product/service identification
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T-Set: 835 - Health Care Claim
Payment/Advice
The EDI 835 transaction set is called Health Care Claim Payment and Remittance Advice
The 835 is used primarily by Healthcare insurance plans to make payments to healthcare providers, to provide Explanations of Benefits (EOBs), or both. When a healthcare service provider submits an 837 Health Care Claim, the insurance plan uses the 835 to detail the payment to that claim, with the following details:
What charges were paid, reduced or denied
Whether there was a deductible, co-insurance, co-pay, etc.
Any bundling or splitting of claims or line items
How the payment was made, such as through a clearinghouse
The 835 is important to healthcare providers, to track what payments were received for services they provided and billed
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T-Set: 837 - Health Care Claim
The EDI 837 transaction set is the format established to meet HIPAA requirements for the electronic submission of healthcare claim information. The claim information included amounts to the following, for a single care encounter between patient and provider:
A description of the patient
The patient’s condition for which treatment was provided
The services provided
The cost of the treatment
The 5010 standards divide the 837 transaction set into three groups, as follows:
837P for professionals
837I for institutions
837D for dental practices. The 837 is no longer used by retail pharmacies.
This transaction set is sent by the providers to payers, which include insurance companies, health maintenance organizations (HMOs), preferred provider organizations (PPOs), or government agencies such as Medicare, Medicaid, etc. These transactions may be sent either directly or indirectly via clearinghouses
Health insurers and other payers send their payments and coordination of benefits information back to providers via the EDI 835 transaction set
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T-Set: 276 - Health Care Claim
Status Request The EDI 276 transaction set is a Health Care Claim Status Inquiry. It is used by healthcare
providers to verify the status of a claim submitted previously to a payer, such as an insurance company, HMO, government agency like Medicare or Medicaid, etc.
The 276 transaction is specified by HIPAA for the electronic submission of claim status requests. The transaction typically includes:
Provider identification
Patient identification
Subscriber information
Date(s) of service(s)
Charges
Submitting a 276 status request to a payer is the first step in the claim status request/response process. The payer provides the requested information in response to the 276 request using a 277 Claim Status Response transaction
The use of EDI 276 inquiries, along with the 277 response, replaces the manual process of managing payments and claims. By submitting the inquiry via EDI with the 276 transaction, administrators can receive the information more quickly and with little or no manual intervention
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T-Set: 277 - Health Care Claim
Status Notification The EDI 277 Health Care Claim Status Response transaction set is used by
healthcare payers (insurance companies, Medicare, etc.) to report on the status of claims (837 transactions) previously submitted by providers
The 277 transaction, which has been specified by HIPAA for the submission of claim status information, can be used in one of the following three ways:
A 277 transaction may be sent in response to a previously received EDI 276 Claim Status Inquiry
A payer may use a 277 to request additional information about a submitted claim (without a 276)
A payer may provide claim status information to a provider using the 277, without receiving a 276
Information provided in a 277 transaction generally indicates where the claim is in process, either as Pending or Finalized. If finalized, the transaction indicates the disposition of the claim – rejected, denied, approved for payment or paid
If the claim was approved or paid, payment information may also be provided in the 277, such as method, date, amount, etc. If the claim has been denied or rejected, the transaction may include an explanation, such as if the patient is not eligible
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HIPAA 4010 to 5010 conversion –
what are the changes?
Version 5010 compliance date – January 1, 2012
With the Version 5010, the formats currently used must be upgraded from X12 Version
Formats that must be upgraded include: Claims (837-I, 837-P)
Remittance Advice (835)
No job requirements currently related to 5010 conversion. But there could be projects related to fixing any issues related to the 4010 – 5010 conversion projects implemented earlier
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ICD-9 to ICD-10 conversion
ICD-9 follows an outdated 1970's medical coding system which fails to capture detailed health care data and is inconsistent with current medical practice. By transitioning to ICD-10, providers will have:
Improved operational processes by classifying detail within codes to accurately process payments and reimbursements
Detailed information on condition, severity, co-morbidities, complications and locations
Detailed health reporting and analytics such as cost, utilization and outcome
Expanded coding flexibility by increasing code length to seven characters
Important Dates:
January 1, 2012 - ALL providers must upgrade to Version 5010 in order to accommodate ICD-10 codes
October 1, 2013 - ICD-10 codes must be used for all procedures and diagnosis on and after this date. Claims with ICD-9 codes for services provided on or after October 1, 2013 cannot be paid. This was extended to 2014 I guess (not sure)
No requirements currently related to ICD-10 conversion. But there could be projects related to fixing any issues related to the ICD-9 – ICD-10 conversion projects implemented earlier
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Care Management/
Case Management
Care management is a set of activities
intended to improve patient care and reduce
the need for medical services by helping
patients and caregivers more effectively
manage health conditions
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Care Management
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CM – goals and objectives
The overall goals of care management are:
1. to optimize the patient’s ability to take care of himself or herself; and
2. to identify and coordinate needed resources and support.
Steps:
1. Patient identification and comprehensive assessment:
Patients are identified through direct referrals, by mining administrative claims data (e.g., risk stratification tools, frequent hospital and emergency room admissions), through screenings and assessments, and through chart reviews that identify gaps in care.
2. Developing an individualized care plan:
The health care team — including the care manager, primary care provider, patient and family/caregiver —agree on goals in a care plan.
3. Care coordination:
The care manager ensures the patient’s care plan is implemented, communicating and coordinating across providers and delivery settings. Care manager interventions are identified and documented.
4. Reassessment and monitoring:
Patient’s progress is monitored toward goal achievement on an ongoing basis, adjusting care plans, as needed.
5. Outcomes and evaluation:
The care manager uses the quality metrics (discussed in Modules 7 and 10), assessment and survey results, and utilization of services to monitor and evaluate the impact of interventions.
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CM Projects
Projects related to System replacement and
Up gradation of analytics capability
Vendors – McKesson, Landacorp, ZeOmega,
Medecision, TriZetto, Click4Care, CaseNet,
DST Health Solutions, ikaSystems
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Medicare
Medicare is a Federal health insurance program that pays for hospital and medical care for elderly and certain disabled Americans
Eligibility:
An individual must either be at least 65 years old, under 65 and disabled, or any age with End-Stage Renal Disease (permanent kidney failure that requires dialysis or a transplant.)
In addition, eligibility for Medicare requires that an individual is a U.S. citizen or permanent legal resident for 5 continuous years and is eligible for Social Security benefits with at least ten years of payments contributed into the system
The program consists of two main parts for hospital and medical insurance (Part A and Part B) and two additional parts that provide flexibility and prescription drugs (Part C and Part D)
Medicare Part A, or Hospital Insurance (HI), helps pay for hospital stays
Medicare Part B is also called Supplementary Medical Insurance (SMI). It helps pay for medically necessary physician visits, outpatient hospital visits, home health care costs, and other services for the aged and disabled
Medicare Advantage Plans (sometimes known as Medicare Part C, or Medicare + Choice) allow users to design a custom plan that can be more closely aligned with their medical needs
In 2006, Medicare expanded to include a prescription drug plan known as Medicare Part D
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Medicare contd.
Supplemental coverage for medical expenses and services that are not covered by Medicare are offered through MediGap plans
Who pays for Medicare?
Payroll taxes collected through FICA (Federal Insurance Contributions Act) and the Self-Employment Contributions Act are a primary component of Medicare funding. The tax is 2.9% of wages, usually half paid by the employee and half paid by the employer
Moneys are set aside in a trust fund that the government uses to reimburse doctors, hospitals, and private insurance companies. Additional funding for Medicare services comes from premiums, deductibles, coinsurance, and copays
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Medicaid
Medicaid is a means-tested health and medical services program for certain individuals and families with low incomes and few resources. Primary oversight of the program is handled at the federal level, but each state: Establishes its own eligibility standards,
Determines the type, amount, duration, and scope of services,
Sets the rate of payment for services, and
Administers its own Medicaid program.
Who is eligible for Medicaid? Each state sets its own Medicaid eligibility guidelines. The
program is geared towards people with low incomes, but eligibility also depends on meeting other requirements based on age, pregnancy status, disability status, other assets, and citizens
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Medicaid contd.
Who pays for services provided by Medicaid?
Medicaid does not pay money to individuals, but operates in a program that sends payments to the health care providers. States make these payments based on a fee-for-service agreement or through prepayment arrangements such as health maintenance organizations (HMOs)
Each State is then reimbursed for a share of their Medicaid expenditures from the Federal Government
States may impose nominal deductibles, coinsurance, or copayments on some Medicaid beneficiaries for certain services. However, the following Medicaid beneficiaries must be excluded from cost sharing:
Pregnant women,
Children under age 18, and
Hospital or nursing home patients who are expected to contribute most of their income to institutional care.
All Medicaid beneficiaries must be exempt from copayments for emergency services and family planning services.
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Consumer-driven health care
(CDHC) Refers to third tier health insurance plans that allow members to use Health savings
accounts (HSAs), Health Reimbursement Accounts (HRAs), or similar medical payment products to pay routine health care expenses directly, while a high-deductible health plan (HDHP) protects them from catastrophic medical expenses
High-deductible policies cost less, but the user pays routine medical claims using a pre-funded spending account, often with a special debit card provided by a bank or insurance plan. If the balance on this account runs out, the user then pays claims just like under a regular deductible. Users keep any unused balance or "rollover" at the end of the year to increase future balances, or to invest for future expenses
Examples:
Flexible spending account (FSA)
Health Reimbursement Account (HRA)
Health savings account (HSA)
High-deductible health plan (HDHP)
Medical savings account (MSA)
Private Fee-For-Service (PFFS)
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Flexible spending account
(FSA) A flexible spending account (FSA), also known as a flexible spending
arrangement, is one of a number of tax-advantaged financial accounts that can be set up through an employer
An FSA allows an employee to set aside a portion of earnings to pay for qualified expenses, most commonly for medical expenses but often for dependent care or other expenses
Money deducted from an employee's pay into an FSA is not subject to payroll taxes, resulting in substantial payroll tax savings
Before the Affordable Care Act, one significant disadvantage to using an FSA is that funds not used by the end of the plan year are lost to the employee, known as the "use it or lose it" rule. Under the terms of the Affordable Care Act, an employee can carryover up to $500 into the next year without losing the funds
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Health Reimbursement Account
(HRA)
Health Reimbursement Accounts or Health Reimbursement Arrangements (HRAs) are Internal Revenue Service (IRS)-sanctioned employer-funded, tax-advantaged employer health benefit plans that reimburse employees for out-of-pocket medical expenses and individual health insurance premiums
Health Reimbursement Accounts are funded solely by the employer, and cannot be funded through employee salary deductions. The employer sets the parameters for the Health Reimbursement Accounts, and unused dollars remain with the employer
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Health savings account (HSA)
A health savings account (HSA) is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a high-deductible health plan (HDHP)
The funds contributed to an account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), funds roll over and accumulate year to year if not spent
HSAs are owned by the individual, which differentiates them from company-owned Health Reimbursement Arrangements (HRA)
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Healthcare Data warehousing
Data warehouse is critical in healthcare industry for reporting and analytics needs
Data from the operational systems handling Claims, Groups, Membership, Eligibility etc is transferred to the data warehouse on a daily basis
It is a normal practice to use the data warehouse for both internal and external reporting needs unless the real time data in required
Data dictionaries provide information related to the tables and the structure of data storage in the warehouse
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Data warehousing contd.
Operationa
l
systems
Staging
area
Data
warehouseReporting (Internal and
external) and analytic needs
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Data warehousing requirements
Reports
Understanding the user requirements
Designing the layout
Defining the elements in the report – business definition without any ambiguity
For example, ‘Member ID’ – define whether it is internal or external Member ID and the number of digits etc.
Other info
Frequency of reporting
Internal or external
Recipients
Mode of delivery
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Data warehousing requirements
Analytics – Third party vendor applications are used by the clients to enable their analytic capabilities
Role
To understand the client requirements related to the analytic capabilities
Coordinating with the vendors on how they would be delivered
Coordinating with tech folks to provide the vendor with the data required for analytics
Explore if the vendor’s standard capabilities could be leveraged for the client needs
Else customize to meet client needs
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Data warehousing requirements
Impact assessment and remediation - Lot of projects in this area
The requirements arise as a result of any project implementation with the operational systems that impact the data flow to the warehouse
It leads to remediation of the data flow, and all the reports and analytics dependent on them
These jobs need an understanding of the business process and the data flow as well
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The Affordable Care Act of 2010
(ACA) – Obamacare – What is it?
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The Affordable Care Act is the nation’s health reform law enacted in March 2010
It contains numerous provisions that will
expand health coverage to 25 million Americans,
increase benefits and lower costs for consumers,
provide new funding for public health and prevention,
bolster our health care and public health workforce and infrastructure,
foster innovation and quality in our system, and more.
The Affordable Care Act of 2010
(ACA) – Obamacare – impacts
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Insurance companies will make some changes as a result of Obama Care
For example, companies can no longer exclude people with pre-existing conditions, and children will be allowed on their parents’ policies until age 26
There are some lesser-known provisions that will impact insurance companies, like the medical loss ratio, for example. The medical loss ratio provision states that 80% of an insurance premium must go to actual paying of coverage and only 20% may be used for overhead, marketing and profit
The good news is that insurance companies avoided the worst possible outcome, which is being subject to market reforms and not having the new, young, healthy people requiring health insurance. With a health insurance mandate, the young and healthy demographic that were previously uninsured will now buy insurance, balancing out the good risk and the bad risk for insurance companies
Boards of insurance companies need to be quite focused on implementation of market place and deadlines in place for 2014
12/18/201444
Claims processing flowchart
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Claims processing flowchart
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HIPAA 4010 to 5010 conversion –
what are the changes? A physical street address must be reported for the billing provider’s service address. A PO Box address will not be
accepted
Only a provider Pay-to address can be a PO Box address
Require 9 digit zip code
Enhanced NPI Reporting rules
Support for atypical providers (taxi drivers, carpenters and personal care providers)
837I - Expansion of the number of Diagnosis Codes
837I - Present on Admission Indicators can now be reported for diagnosis codes
837P - Supports Ambulance related billing
837P - Allows reporting of Anesthesia units only in minutes
Coordination of Benefits – clarification and enhancements on how to report primary, secondary and tertiary payers for claims transactions
Remaining Patient Liability can now be calculated for claims transactions
Adjustment reporting has been clarified now allowing for the Primary payer claim level adjustment codes reported in the 835 to be sent to the Secondary payer
835 - New sections have been added to organize the payment remittance process
835 - Claim splitting has been clarified by specifying the use of the MIA or MOA segments
835 - Segment has been added for Lost and Reissue Payment to prevent recreation or retransmittal
of a remittance
835 - Encounter reporting has been clarified
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