This article provides a brief overview of the US Healthcare System, US Healthcare Domain Knowledge for the business analyst and how does us healthcare system work.
Healthcare Domain Knowledge – US Healthcare System Overview
The health care industry is one of the largest industries in the world, and it has a direct effect on the quality of life of people in each country. Health care (or healthcare) is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans.
Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers. The health care industry, or medical industry, is a sector that provides goods and services to treat patients with curative, preventive, rehabilitative or palliative care.
The US healthcare system is the best healthcare system in the world. Find the below list of main entities of us healthcare model:-
- Healthcare Provider/Doctor/Hospital/Facility
- Health Insurance Provider/Payer
- Group and
- Federal and State Governments
Understanding US Healthcare System
- Health Insurance: It will be a contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
- Insurer/Payer: The insurance company whose plan pays to help cover the cost of your care.
- Primary Insurer: The insurance plan processes the claim first when a member has more than one group insurance plan covering the services.
- US Healthcare Providers: It can be any person (doctor or nurse)/institution (hospital, clinic or laboratory) that provides medical care.
- Member/Subscriber: A person who is enrolled in a health plan (also called an enrollee or subscriber)
- Group: It can be an Employer, Group Insurance
- Plan: An individual or group plan that provides, or pays the cost of medical care.
US Healthcare System Structure – How does US healthcare system work?
Let’s look at the various steps of a typical US healthcare system structure. It shows that how does US healthcare system work with the help of pictorial representation:-
*EOB: Explanation of Benefits, which is a statement of the insurer that itemizes how benefits were approved or denied a claim.
US Healthcare System Terminology
In addition to US healthcare domain knowledge, US healthcare terminology can be complex, to say the least. Find the list below:-
- Healthcare plan
- Coverage Type
- Enrollment, Effective and Termination Dates
- FSA (Flexible spending accounts or arrangements)
- MSA (Medical saving account) / HSA (Health spending account)
- ICD Codes – ICD9 vs. ICD10
- HL7 (Inbound/Outbound)
- Section 111 Reporting
Government Health Care Plans
Commercial Healthcare Plans
- Preferred provider organization (PPO)
- Exclusive provider organization (EPO)
- Health maintenance organization (HMO)
- Supplemental Insurance
- What is HIPAA (Health Insurance Portability and Accountability Act)?
- HIPAA Basics
- HIPAA Transactions
- 837: Claim submission (Professional, Institutional, and Dental)
- 834: Enrollment (Benefits Enrollment and Maintenance)
- 820: Premium Payments (Payroll Deducted and other group payment)
- 270/271: Eligibility and benefits (Healthcare eligibility inquiry and response)
- 278: Authorization (Healthcare service request for review and response)
- 4010 to 5010 conversion
- Member management
- Provider management
- Reimbursement Management (Claim Processing)
- Benefits Administration
- Prior Authorization
- Rate Setting
ICD 9 and ICD 10 Conversion
- What are ICD codes?
- Benefits of conversion
- Things to accounts for
- Analysis Guidelines
- Testing Considerations
COB and TPL
- Coordination of Benefits (COB)
- What is COB
- Why COB
- COB Rules
- Third Party Liability (TPL)
- What is TPL
- Why TPL
- TPL Rules
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