Healthcare Market Overview

• Introduction
• Current healthcare market trend in US
• What is an HMO
• The Industry Outlook
• Trends in Healthcare – Provider Space
• Trends in Healthcare – Payer Space
• Key Players
• References

Healthcare Overview

• Unit Objectives
• Genesis Of Healthcare
• How the industry Works?
• Healthcare pillars
• Members
• Providers
• Benefits
• Claims
• Sales
• External Agents
• Healthcare workflow
• Summary
• Review Questions
• References

Members

• Unit Objective
• Introduction
• Insurance Business: An Overview
• Individual and Group Insurance in detail
• Individual Insurance
• How to get individual insurance?
• Group Insurance
• Company Paid Groups
• Affinity Groups
• Self Insured Group
• Self-Employed Members
• Exercise

Member’s enrolment

• What is Enrollment?
• How is enrollment carried out?
• Output of enrollment process
• Enrollment: Overall Picture
• Exercise

Member’s and Dependent’s eligibility

• Eligibility
• Eligibility Process
• How a member should approach right provider?
• Eligibility Data Transfer
• Eligible Dependents
• Exercise

Member Services

• Means of services
• Services provided by the insurer
• Premium Collection
• Member Group Maintenance
• What are Groups?
• Groups Formation
• Groups Maintenance
• Disability Benefits
• Member’s concern
• Exercise

Provider

• Provider types
• Provider Participation
• Provider Contract
• Provider Contract Process
• Credentialing Criteria
• Verification of Provider Credentialing Information
• Types of Contracts
• Provider Reimbursement
• Exercise
• Provider Referral
• Referrals processing
• Referral types
• Provider Network
• Quality Provider Networks
• Network Adequacy
• Rental networks
• Network Hospital Standards
• Provider maintenance
• some common information of Providers
• Exercise
• Review Questions
• References

Sales

• Unit Objectives
• Introduction
• Brokers
• Calculation for Brokers
• Quote Creation
• What is a quote?
• The Process Of Quote Creation
• Actuaries
• Underwriters
• Insurance Payer’s Sales Department
• External Agents that deal with Sales Department of Insurance Payers
• Review Questions

Benefits

• Unit Objectives
• Introduction
• Indemnity Plans
• Managed Care Plans
• Health Maintenance Organization (HMO)
• Preferred Provider Organization (PPO)
• Point Of Service (POS)
• Exclusive Provider Organization (EPO)
• Which plan is the best?
• Exercise
• Other Plans
• Vision Plans
• Dental Plans
• Pharmacy Plans
• Medicare Plans
• Medigap
• Medicaid
• Long Term Care
• Disability Income Insurance
• Catastrophic Coverage Plans
• Exercise
• Individual Insurance and Group Insurance
• Laws and Legislations
• Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA)
• Health Insurance Portability and Accountability Act (HIPAA)
• Review Questions
• References

Claims

• Claim generation and submission to Providers
• Claims Intake Process
• Claims Intake : Diagrammatic
• Claim Adjudication Process
• Claim Preparation and determining eligibility
• Determine payment
• Update Claim
• Claim adjudication outputs
• Claim Payments
• Provider Payments
• Member Re-imbursement
• Member Re-imbursement
• Refund Adjustment
• Minus Debit Adjustment
• Minus Debit Adjustment
• Minus Debit Adjustment
• Stop Adjustment
• Government reporting
• Explanation of Benefits (EOB)
• Accumulators
• What are Accumulators?
• Function/Purpose of Accumulators
• What is accumulated?
• Types of Accumulator
• Overall Claims system diagram
• Review Questions
• References

External Agents

• Unit Objectives
• Introduction
• Government Agencies
• Centers for Medicare & Medicaid Services (CMS)
• DEPARTMENT OF HEALTH AND HUMAN SERVICES (DHSS)
• Centers for Disease Control and Prevention (CDC)
• Agency for Health Care Research and Quality (AHRQ)
• National Information Center on Health Services Research and Health Care Technology (NICHSR)
• Health Resources and Services Administration (HRSA)
• Exercise
• Government Acts and Regulations
• HIPAA
• ELECTRONIC HEALTH TRANSACTIONS STANDARDS
• CORBA
• Exercise
• Clearing Houses
• Benefits Of A Clearinghouse
• Clearinghouse versus Direct Filing
• Clearinghouse Income
• Exercise
• Third Party Administrators
• Specialized Adjudication Engines/Companies
• General Agents
• Accreditation Agencies
• The Accreditation Process
• Drug Manufacturers
• Review Questions
• References

Summary

• Unit Objectives
• Workflow
• The Beginning: Member wants to purchase insurance
• Getting a provider
• An Enrolled member wants to seek medical services.
• Member has filed a claim
• Effect of external agencies
• Review Questions
• References.

Appendices

• Total E-Business Services Forecast for Healthcare
• The world Healthcare market and Healthcare IT spending
• The Cash Flux of the US Healthcare Industry
• Sample Quote Sheet