Introduction to

US Healthcare

History

• Patients paid directly• Help from religious and charitable organizations• Technology Advances in healthcare made free care more expensive• Health insurance was created to alleviate

– Patients risk of not being able to pay for future medical costs– Providers risk of not being paid for the services rendered

• Large percentage of US population has health insurance through– Employers– Government– Private carriers

Health Insurance

• Health insurance is a mechanism to reduce individual’s risk of incurring high medical expenses in the future that he may be unable to pay. In order to cover these possible future medical expenses a person pays periodic payments (premiums), to an insurance company. These Premium payments allow that person to be enrolled with the company.

That person is referred to as an “enrollee” or “insured”.

Insurance Plan

• Insurance coverage is referred to as an “insurance plan” and covers services that were previously agreed to. Individual is given a health insurance card on purchase of the “insurance plan”, which contains details of the patient’s insurance policy.

• A policyholder is not eligible for health insurance unless and until he/she pays the pre-determined premium specified by the insurance.

• Components of Insurance Plan– Premium to be paid– Services covered– Services not covered– Patient’s responsibility on a bill/claim– Provider network

Steps Involved

• How is provider paid by health insurance• Reimbursement process

– When a provider first sees a patient for treatment, the patient’s health insurance and clinical information is compiled.

– After treating a patient, the provider sends a bill directly to the patient’s insurance carrier. This provider bill is called a claim.

– The patient’s insurance carrier pays for the patient’s covered services by sending a payment directly to the provider.

– If provider is not paid completely than the bill for remaining amount/services is sent to the patient– If the patient does not have health insurance, he is responsible for the entire provider bill.

• Objectives of billing company– Offer fast, efficient, and error free claims processing,– Collect money due from insurance company,– Zero out balance on a patient record, and– Collates information and generates reports.

Participants in US Healthcare system

• Patients – Beneficiary– A new patient – not seen since 36 months– Established patient – got treated once/many times within 36 months

• Providers– Providers are individuals, corporations, institutions, or facilities – Examples of providers: Physicians, Nurses, Hospitals, and Nursing homes, Emergency room

technicians, Ambulatory surgery centers.

• Payers – Insurance companies: Government or Private companies

• Suppliers– organizations that sell healthcare products to providers to be used in the delivery of healthcare.

Examples of suppliers: Merck, Johnson and Johnson

• Researchers– Researchers lead to technological advances in healthcare

• Business Associates– Receives or reveals PHI of covered entities (patients) on its behalf only if the covered entity executes a

satisfactory contract or other written agreement (Ex: Memorandum of Understanding).

Care Extended at Hospitals

• Inpatient : A person who is admitted to the hospital so that he may receive care overnight.

• Outpatient : A person who receives hospital services but does not need to receive care overnight; outpatients are not admitted but can be under observation for some hours.

• Emergency : A person who requires immediate service because the illness is severe or life threatening.

Types of Payers

• Medicare• Medicaid• Blue Cross and Blue Shield• Commercial Insurance• Managed care Organizations• Worker’s Compensation• No-Fault• TRICARE

FAQ’s

• Are the claims generated in between the treatment process. - No

Abbrievations

• NIH : National institute of health • PCP : Primary care physicians• ASC : Ambulatory surgery center• SNF : Skilled nursing facility• SDS : Same day service• SPU : Short procedure unit• UPIN : Unique Physician Identification Number• PHI : Protected Health Information• HIPAA : Health Insurance Portability and Accountability Act• CMS : Centre for Medicare and Medicaid Services• ESRD : End-Stage Renal Disease• BCBS : Blue Cross and Blue Shield• FEP : Federal Employee Program• EGHP : Employee Group Health Plan• LGHP : Large Group Health Plan• HMO : Health Maintenance Organization• PPO : Preferred Provider Organization• POS : Point Of Service• CHAMPUS : Civilian Health And Medical Program for Uniformed Services• CHAMPVA : Civilian Health And Medical Program for Veteran Administration• EOB : Explanation of Benefits