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Healthcare Domain Course Material

Healthcare Domain Course Material

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Published by: senthilj82 on Aug 22, 2011
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  • 1.5References
  • 2Healthcare Overview
  • 2.1Unit Objectives
  • 2.2Genesis Of Healthcare
  • 2.3How the industry Works?
  • 2.4Healthcare pillars
  • 2.4.6External Agents
  • 2.5Healthcare workflow
  • 2.7Review Questions
  • 2.8References
  • 3Members
  • 3.1Unit Objective
  • 3.2.1Insurance Business: An Overview
  • 3.3Individual and Group Insurance in detail
  • 3.3.1Individual Insurance
  • 3.3.2How to get individual insurance?
  • 3.3.3Group Insurance
  • 3.3.4Company Paid Groups
  • 3.3.5Affinity Groups
  • 3.3.6Self Insured Group
  • 3.4Member’s enrollment
  • 3.4.1What is Enrollment?
  • 3.4.2How is enrollment carried out?
  • 3.4.3Output of enrollment process
  • 3.4.4Enrollment: Overall Picture
  • 3.5Member’s and Dependent’s eligibility
  • 3.5.1Eligibility
  • 3.5.2Eligibility Process
  • 3.5.3How a member should approach right provider?
  • 3.5.4Eligibility Data Transfer
  • 3.5.5Eligible Dependents
  • 3.6Member Services
  • 3.6.1Means of services
  • 3.7Premium Collection
  • 3.8Member Group Maintenance
  • 3.8.1What are Groups?
  • 3.8.2Groups Formation
  • 3.8.3Groups Maintenance
  • 3.9Disability Benefits
  • 3.9.1Member’s concern
  • 4Provider
  • 4.1Provider types
  • 4.2Provider Participation
  • 4.3Provider Contract
  • 4.3.1 Provider Contract Process
  • 4.3.2 Credentialing Criteria
  • 4.3.3 Verification of Provider Credentialing Information
  • 4.3.4 Types of Contracts
  • 4.3.5 Provider Reimbursement
  • 4.5Provider Referral
  • 4.5.1 Referrals processing
  • 4.5.2 Referral types
  • 4.6Provider Network
  • 4.6.1 Quality Provider Networks
  • 4.6.4 Network Hospital Standards
  • 4.7Provider maintenance
  • 4.7.1 some common information of Providers
  • 4.9Review Questions
  • 4.10References
  • 5Sales
  • 5.1Unit Objectives
  • 5.3.1Calculation for Brokers
  • 5.4Quote Creation
  • 5.4.1What is a quote?
  • 5.4.2The Process Of Quote Creation
  • 5.5Actuaries
  • 5.7Insurance Payer’s Sales Department
  • 5.7.1External Agents that deal with Sales Department of Insurance Payers
  • 5.8Review Questions
  • 6Benefits
  • 6.1Unit Objectives
  • 6.3Indemnity Plans
  • 6.4Managed Care Plans
  • 6.4.1Health Maintenance Organization (HMO)
  • 6.4.2Preferred Provider Organization (PPO)
  • 6.4.3Point Of Service (POS)
  • 6.4.4Exclusive Provider Organization (EPO)
  • 6.5Which plan is the best?
  • 6.6.3Pharmacy Plans
  • 6.6.4Medicare Plans
  • 6.6.7Long Term Care
  • 6.6.8Disability Income Insurance
  • 6.6.9Catastrophic Coverage Plans
  • 6.6.10 Exercise
  • 6.8Laws and Legislations
  • 6.8.1Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA)
  • 6.8.2Health Insurance Portability and Accountability Act (HIPAA)
  • 6.9Review Questions
  • 6.10References
  • 7Claims
  • 7.1Claim generation and submission to Providers
  • 7.1.1Claims Intake Process
  • 7.1.2Claims Intake : Diagrammatic
  • 7.2Claim Adjudication Process
  • 7.2.1Claim Preparation and determining eligibility
  • 7.2.2Determine payment
  • 7.2.4Claim adjudication outputs
  • 7.3Claim Payments
  • 7.3.1Provider Payments
  • 7.3.2Member Re-imbursement
  • 7.4Claim Adjustments
  • 7.4.1Refund Adjustment
  • 7.4.2Minus Debit Adjustment
  • 7.4.3Manual Check Adjustment
  • 7.4.4Void Adjustment
  • 7.4.5Stop Adjustment
  • 7.5Government reporting
  • 7.6Explanation of Benefits (EOB)
  • are Accumulators?
  • of Accumulators
  • 7.7.3What is accumulated?
  • 7.8Overall Claims system diagram :
  • 7.9Review Questions
  • 8External Agents
  • 8.1Unit Objectives
  • 8.3Government Agencies
  • 8.3.1Centers for Medicare & Medicaid Services (CMS)
  • 8.3.3Centers for Disease Control and Prevention (CDC)
  • 8.3.4Agency for Health Care Research and Quality (AHRQ)
  • 8.3.6Health Resources and Services Administration (HRSA)
  • 8.4Government Acts and Regulations
  • 8.5Clearing Houses
  • 8.5.1Benefits Of A Clearinghouse
  • 8.5.2Clearinghouse versus Direct Filing
  • 8.5.3Clearinghouse Income
  • 8.6Third Party Administrators
  • 8.7Specialized Adjudication Engines/Companies Adjudicator
  • 8.9Accreditation Agencies
  • 8.9.1The Accreditation Process
  • 8.10Drug Manufacturers
  • 8.11Review Questions
  • 8.12References
  • 9Summary
  • 9.1Unit Objectives
  • 9.2.1The Beginning: Member wants to purchase insurance
  • 9.2.2Getting a provider
  • 9.2.3An Enrolled member wants to seek medical services
  • 9.2.4 Member has filed a claim
  • 9.2.5Effect of external agencies
  • 9.3Review Questions
  • 9.4References
  • 10Appendices
  • 10.1Appendix A: Total E-Business Services Forecast for Healthcare
  • 10.2Appendix B: The world Healthcare market and Healthcare IT spending
  • (Source: Gartner Research, Inc)
  • 10.3Appendix C: The Cash Flux of the US Healthcare Industry
  • 10.4Appendix C: Sample Quote Sheet
  • 11Glossary

Pharmacy plans enable the members to buy prescription drugs from participating or non-
participating pharmacists at lower rates against a premium amount paid for the Plans. They
usually involve a ‘Managed Pharmacy Benefit Network’ (network of pharmacists which
contracts with the Insurer), which offers drugs to plan holders at reduced rates.

Most pharmacy plans that pay for prescription drug benefits have benefit tiers that group
certain medications together for pricing purposes. Brand-name drugs that are usually in the
top tier are most expensive; while generic medications are in the lower tier and are least
expensive .The types of drugs can be classified as -

Branded drugs – which are patented drugs (10 yrs patent) and hence costly.

Generic Drugs - which are Non-patented drugs with same chemical
compositions and are relatively cheaper.

Non-Formulary drugs - which are the cheapest.

Most health plans have three or four pharmacy benefit tiers, but some have as many as
seven. The typical three tiers of a pharmacy plans are -

1.Single tier plans

Fixed copay for all types of drugs mentioned in the plan.

2.Two tier plans

Lower copay for Generic drugs

Higher copay for Branded drugs


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3. Three tier plans

Lowest copay for Generic drugs

Medium copay for branded drugs

Highest copay for Non formulary drugs

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