Healthcare Domain Basic Knowledge

In the previous article, I have explained what is domain knowledge and the importance of domain knowledge in the IT software industry. In this article, I will explain about healthcare domain basic knowledge in brief.

About Healthcare Domain Knowledge

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.

• Keep reading on Hospital Management System Software

Health Care Terminology

• Subscriber
• Member
• Provider
• Claims
• Coinsurance
• Copayment
• Deductible
• FSA
• MSA
• In-depth Terminology
  • Coverage Type
  • Enrollment, Effective and Termination Dates
  • Capitation etc.
• PHI
• HIPAA
• Health Care Plans
• COB
• TPL
• ICD Codes – ICD9 vs. ICD10
• HL7

Commercial Health Care Plans

• Preferred provider organization (PPO)
• Exclusive provider organization (EPO)
• Health maintenance organization (HMO)
• Supplemental Insurance
• Medigap

Government Health Care Plans

• Medicaid
  • Eligibility
  • Coverage
• Medicare
  • Eligibility
  • Coverage

Health Insurance Portability and Accountability Act (HIPAA)

• What is HIPAA?
• HIPAA Basics
• HIPAA Transactions
  • 837 – Claims submission (Professional / Institutional and Dental)
  • 834 – Enrollment (Benefit Enrollment and Maintenance)
  • 820 – Premium Payments (Payroll Deducted and Other Group Payments)
  • 270/271 – Eligibility and Benefits (Health Care Eligibility Inquiry and Response)
  • 278 – Authorization (Health Care Services Request for Review and Response)
• 4010 to 5010 conversion

Health Care Systems

• Member Management
• Provider Management
• Reimbursement Management (Claims Processing)
• Benefits Administration
• Prior Authorization
• Rate Setting

ICD 9 to ICD 10 Conversion

• What are the ICD Codes?
• Benefits of Conversion?
• Concerns
• Things to account 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

Health Care Basics

• Subscriber: Person who pays the premium and under whom the family is covered.

• Member: Who receives medical coverage under a subscriber. Dependents of the family.

• Provider: In simple words, any place where we can go and get treatment. Formal definition “Any individual, institution, or agency that provides health services to health care consumers.”

• Claims: An invoice from the provider to the doctor for the services rendered.

• Coinsurance: A form of medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage of medical expenses after the deductible amount, if any, was paid.

• Copayment: A form of medical cost sharing in a health insurance plan that requires an insured person to pay a fixed dollar amount when a medical service is received. The insurer is responsible for the rest of the reimbursement.

• Deductible: A fixed dollar amount during the benefit period – usually a year – that an insured person pays before the insurer starts to make payments for covered medical services.

• FSA (Flexible spending accounts or arrangements): Accounts offered and administered by employers that provide a way for employees to set aside, out of their paycheck, pretax dollars. I can pay only medical expenses. Money lost if unused. FSA can cover childcare expenses if set up separately.

• MSA (Medical Savings Account) / HSA (Health Spending Account) – Savings accounts designated for out-of-pocket medical expenses. Employers and Employees can contribute to this and are pre-taxed. Can carry unused funds into the future year. Are normally combined with high-deductible or catastrophic health insurance plans.

• Fully Insured Plan – A plan where the employer contracts with another organization to assume financial responsibility for the enrollees’ medical claims and for all incurred administrative costs.

Conclusion

I hope you liked this article about healthcare domain knowledge basic fundamentals. I would like to have feedback from my blog readers. Your valuable feedback, question, or comments about this article are always welcome.