Healthcare Domain Knowledge for Interviews Part 3

Healthcare Domain Knowledge for Interviews Part 3
continued from part 2
The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
* Protects health insurance coverage for workers and their families when they change or lose their jobs.
* Administrative Simplification provision is composed of four parts, each of which have generated a variety of "rules" promulgated by the Department of Health and Human Services.
The four parts of Administrative Simplification are:
* Standards for Electronic Transactions
* Unique Identifiers Standards
* Security Rule
* Privacy Rule
Standards for Electronic Transactions :
* Electronic Health Transactions includes health claims, health plan eligibility, enrollment and disenrollment, payments for care and health plan premiums, claim status, first injury reports, coordination of benefits, and related transactions.
* In the past, health providers and plans have used many different electronic formats to transact medical claims and related business. Implementing a national standard is intended to result in the use of one format, thereby "simplifying" and improving transactions efficiency nationwide.
* Virtually all health plans must adopt these standards. Providers using non-electronic transactions are not required to adopt the standards for use with commercial healthcare payers. However, electronic transactions are required by Medicare, and all Medicare providers must adopt the standards for these transactions. If they don't, they will have to contract with a clearinghouse to provide translation services.
Unique Identifiers Standards:
In the past, healthcare organizations have used multiple identification formats when conducting business with each other – a confusing, error-prone and costly approach. It is expected that standard identifiers will reduce these problems. The Employer Identifier Standard, published in 2002, adopts an employer's tax ID number or employer identification number (EIN) as the standard for electronic transactions. Final standards for Provider and Health Plan identifiers have not yet been published.
Privacy Rule:
* Give patients new rights to access their medical records, restrict access by others, request changes, and to learn how they have been accessed
* Restrict most disclosures of protected health information to the minimum needed for healthcare treatment and business operations
* Provide that all patients are formally notified of covered entities' privacy practices,
* Enable patients to decide if they will authorize disclosure of their protected health information (PHI) for uses other than treatment or healthcare business operations
* Establish new criminal and civil sanctions for improper use or disclosure of PHI
* Establish new requirements for access to records by researchers and others
* Establish business associate agreements with business partners that safeguard their use and disclosure of PHI.
HIPAA Transactions
270 Eligibility enquiry
271 Eligibility enquiry response
276 Claim status enquiry
277 Claim status enquiry response
837 Inbound claims
835 Remittance advise
HIPAA 270/271:
* General Requests
* eligibility status (i.e., active or not active in the plan)
* maximum benefits (policy limits)
* exclusions
* in-plan/out-of-plan benefits
* C.O.B information
* deductible
* co-pays
Specific Requests
* procedure coverage dates
* procedure coverage maximum amount(s) allowed
* deductible amount(s)
* remaining deductible amount(s)
* co-insurance amount(s)
* co-pay amount(s)
* coverage limitation percentage
* patient responsibility amount(s)
* non-covered amount(s)
HIPAA 270/271 Flow:

The Health Plan Employer Data and Information Set (HEDIS®)

A set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans.
The performance measures in HEDIS are related to many significant public health issues such as cancer, heart disease, smoking, asthma and diabetes.
HEDIS also includes a standardized survey of consumers' experiences that evaluates plan performance in areas such as customer service, access to care and claims possessing.
HEDIS is sponsored, supported and maintained by NCQA.

Healthcare Domain Knowledge for Interviews Part 2

Healthcare Domain Knowledge for Interviews Part 2
continue from Part 1
POS:
* Point-of-service plans are health benefit arrangements that evolved in response to consumer desire for broader choice in physicians and health care facilities. Health maintenance organizations offer POS plans to give their members a choice of either in-network benefits or out-of-network benefits.
* "In-network" refers to health care professionals and facilities that are members of the health plan's provider network. They are usually listed as "participating providers" in membership materials. Except in special cases, such as emergency treatment, HMOs usually cover care delivered by in-network providers only.
* "Out of network" refers to health care professionals who have no contractual relationship with the health plan. Out-of-pocket costs vary according to how a member chooses to receive care at the "point of service" (hence the name).
Defined Contribution Plan
* Involve employer funding of a fixed (as opposed to variable) dollar amount for health benefits, which employees may then use to purchase benefits from an employer arranged funding mechanism.
* The benefits could either be group benefits packaged and arranged by the employer, or purchased individually by the employees.
Carrier vs. Payer
Carrier
An insurer; an underwriter of risk that finances health care. Also refers to any organization, which underwrites or administers life, health or other insurance programs. When an employer has a “self-insured” plan, the carrier (such as Aetna or Blue Cross) may not serve as carrier in this case, but may serve only as “third party administrator.
Payer :
The public or private organization that is responsible for payment for health care expenses. Payers may be insurance companies or self-insured employers.
Medicare
* A federal program that pays for certain health care expenses for people aged 65 or older. Enrolled individuals must pay deductibles and co-payments, but much of their medical costs are covered by the program.
* Medicare is less comprehensive than some other health care programs, but it is an important source of post- retirement health care.
* Medicare is divided into three parts.
* Part A covers hospital bills,
* Part B covers doctor bills, and
* Part C provides the option to choose from a package of health care plans.
Medicaid
* State programs of public assistance to persons regardless of age whose income and resources are insufficient to pay for health care.
* The United States federal government provides matching funds to the state Medicaid programs.
Coordination of Benefits (COB)
* Provision regulating payments to eliminate duplicate coverage when a claimant is covered by multiple group plans. The procedures set forth in a Subscription Agreement to determine which coverage is primary for payment of benefits to Members with duplicate coverage.
* A coordination of benefits, or "nonduplication," clause in either policy prevents double payment by making one insurer the primary payer, and assuring that not more than 100 percent of the cost is covered. Standard rules determine which of two or more plans, each having COB provisions, pays its benefits in full and which becomes the supplementary payer on a claim.
* Also called cross-over

continued in Part3 click here