HEALTH INSURANCE DOMAIN

BASICS
 Main Entities
2

Healthcare Provider/ Health insurance

Doctor/ Provider/
Hospital/ Carrier
Facility

Member/Subscriber Group Federal and State

governments

12/16/2019
 Basic terminology
3

 Health Insurance - A contract that requires your health insurer to pay some or all of your
health care costs in exchange for a Premium

 Health insurance provider - the health insurance company whose plan pays to help cover the
cost of your care. Also called Payer or Carrier

 Healthcare provider - Any person (doctor or nurse) or institution (hospital, clinic, or laboratory)
that provides medical care

 Preferred Provider - A provider who has a contract with your health insurer or plan to provide
services to you at a discount

 Facility - hospital setting

 Member - A person who is enrolled in a health plan (also called an enrollee or subscriber)

 Group - Employer, group insurance

12/16/2019
 Basic terminology
4

 Insurance plan - plan selected by the member or group for

coverage, based on the premium and benefits

 Premium - the amount a plan member or employer pays each month

in exchange for insurance coverage

 Effective date - the date on which a policyholder's coverage begins

 Benefits - specific areas of cover that offer protection against

financial loss or damage

 Claim - a request by a plan member's health care provider, for the

insurance company to pay for medical services

12/16/2019
 Basic terminology
5

 Coinsurance: An arrangement under which the member pays a fixed percentage of the cost of
medical care after the deductible has been paid. For example, an insurance company might
pay 80 percent of the allowable charge, with the member responsible for the remaining 20
percent; the 20 percent amount is then referred to as the coinsurance amount

 Copayment: One of the ways the member shares medical costs. For example, a flat fee for
certain medical expenses (e.g., $10 for every visit to the doctor), while your insurance
company pays the rest

 Deductible: The amount of eligible expenses a member must pay each calendar year (or
contract year) before the insurance company will make a payment for eligible benefits.
Usually applies to the out-of-network services, but may apply to in-network services for
certain products

 Allowed amount: Maximum amount on which payment is based for covered health care
services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If
the provider charges more than the allowed amount, the member may have to pay the
difference

12/16/2019
 Types of health insurance
6

 Indemnity plans – These major medical plans typically have a deductible (the amount you pay before the
insurance company begins paying benefits). After your covered expenses exceed the deductible amount,
benefits usually are paid as a percentage of actual expenses, often 80 percent. These plans usually
provide the most flexibility in choosing where to receive care.

 Preferred Provider Organization (PPO) plans – In these major medical plans, the insurance company enters
into contracts with selected hospitals and doctors to furnish services at a discounted rate. As a member of a
PPO, you may be able to seek care from a doctor or hospital that is not a preferred provider, but you will
probably have to pay a higher deductible or co-payment.

 Health Maintenance Organization (HMO) plans – These major medical plans usually make you choose a
primary care physician (PCP) from a list of network providers. Your PCP is responsible for managing all of
your healthcare. If you need care from any network provider other than your PCP, you may have to get a
referral from your PCP to see that provider. You must receive care from a network provider in order to have
your claim paid through the HMO. Treatment received outside the network is usually not covered, or covered
at a significantly reduced level.

 Point of Service (POS) plans – These major medical plans are a hybrid of the PPO and HMO models. They
are more flexible than HMOs, but do require you to select a primary care physician (PCP). Like a PPO, you
can go to an out-of-network provider and pay more of the cost. However, if the PCP refers you to an out-
of-network doctor, the health plan will pay the cost.

12/16/2019
 Claims processing – steps
7

 A member with valid health insurance visits an in-network healthcare provider for a
doctor service

 The healthcare provider renders a service

 The healthcare provider submits a claim to health insurance provider

 The health insurance provider processes the claim

 If the member has a financial responsibility (other than an office visit co-pay), the
member will receive and Explanation of Benefits (EOBs) detailing what the health
insurance provider has paid. The member may sign up to receive your EOB
electronically

 The healthcare provider will send a bill to the member if a balance needs to be
paid

12/16/2019
 Explanation of benefits (EOBs)
8

 An explanation of benefits (commonly referred to as an EOB form) is a statement sent by a health insurance
company to covered individuals explaining what medical treatments and/or services were paid for on their
behalf

 An EOB typically describes:

 the payee, the payer and the patient
 the service performed
 the date of the service,
 the description and/or insurer's code for the service,
 the name of the person or place that provided the service, and
 the name of the patient
 the doctor's fee, and what the insurer allows—the amount initially claimed by the doctor or hospital, minus any reductions
applied by the insurer
 the amount the patient is responsible for
 adjustment reasons, adjustment codes

 EOB documents are protected health information. Electronic EOB documents are called edit 835 5010 files

 There normally also will be at least a brief explanation of any claims that were denied, along with a point
to start an appeal

12/16/2019
 Final statuses attached to a claim
9

 Finalized
 Paid

 Denied

 Revised – adjudication information has been changed

 Pending – claims put on hold for more information

or claims in the process of adjudication in the system

12/16/2019
 Claims pricing based on DRG
10

 DRG – Diagnosis Related Grouping

 DRG is a classification based on clinical factors and utilization of resources
 DRG pricing is used only for inpatient admissions. Other hospital visits use
different pricing methods
 DRG pricing is a fixed payment methodology based on two primary
factors:
 Negotiated rates with the facility (based on a patient's coverage)
 Every hospital negotiates its own rates with a payer, known as Standard Base Rate
(SBR). These rates are based on the hospital's patient mix, the size of the facility, and
the hospital's average charges for treating specific conditions.
 Normal resource consumption for the patient's case
 Normal resource consumption is the average amount of resources used to treat any
given condition. Resources include anything that hospitals use to treat and care for a
patient - food, band-aids, medication, x-rays, surgery, nurses time and anything else
required.
 Related claims eligible for DRG pricing are grouped together and paid in
lump sum amount

12/16/2019
 Appeals
11

 If your health insurer refuses to pay a claim or ends your coverage, you have the
right to appeal the decision and have it reviewed either internally or by a third
party

 You can ask that your insurance company reconsider its decision. Insurers have to tell
you why they’ve denied your claim or ended your coverage. And they have to let
you know how you can dispute their decisions

 There are two ways to appeal a health plan decision:

 Internal appeal: If your claim is denied or your health insurance coverage cancelled, you
have the right to an internal appeal. You may ask your insurance company to conduct a
full and fair review of its decision. If the case is urgent, your insurance company must
speed up this process

 External review: You have the right to take your appeal to an independent third party for
review. This is called external review. External review means that the insurance company
no longer gets the final say over whether to pay a claim

12/16/2019
 Eligibility & Benefits
12

 Patient eligibility and benefits should be verified prior to every scheduled appointment

 Eligibility and benefit quotes include membership verification, coverage status and other important information, such as
applicable copayment, coinsurance and deductible amounts

 It’s strongly recommended that providers ask to see the member’s ID card for current information and photo ID in order to
guard against medical identity theft. When services may not be covered, members should be notified that they may be billed
directly

 Generally members and Providers have access to the following info, online or through telephone:
 Patient/Subscriber information
 Group Number
 Group Name
 Plan/Product
 Current Effective Dates
 Copayment*
 Deductible (original and remaining amounts)
 Out-of-pocket (original and remaining amounts)
 Coinsurance
 Limitations/Maximums*
 Preauthorization indicators and contacts

12/16/2019
 (Prior/Pre) Authorization process
13

 A prior authorization is an extra step that some insurance companies require before they
decide if they want to pay for the doctor services

 Some medical procedures and drugs need prior authorization from the Insurance providers

 During this process, the insurance provider may request and review medical records, test
results and other information so that they understand what services are being performed, and
are able to make an informed decision

 It’ll be determined if the requested service(s) are medically necessary and identified as
covered services under the terms of your health insurance plan based on the information
available

 Typically notified either in writing, or via telephone within two business days of receiving all
necessary documentation. In addition, the member portal of our website gives the status of
your authorization online

 Emergencies do not need prior authorization

12/16/2019
 EDI transaction sets in healthcare
14

 EDI – Electronic Data Interchange

 HIPAA mandates EDI standards

 As of March 31, 2012, healthcare providers must be compliant with version 5010
of the HIPAA EDI standards. The earlier version was 4010

 HIPAA - Health Insurance Portability and Accountability Act

 Enacted in 1996

 Title I of HIPAA protects health insurance coverage for workers and their families when
they change or lose their jobs

 Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the
establishment of national standards for electronic health care transactions and national
identifiers for providers, health insurance plans, and employers

12/16/2019
 EDI transaction sets in healthcare
15

 The following are the common EDI transaction sets in

healthcare:
 T-Set: 270 - Eligibility, Coverage or Benefit Inquiry
 T-Set: 271 - Eligibility, Coverage or Benefit Information

 T-Set: 834 - Benefit Enrollment and Maintenance

 T-Set: 835 - Health Care Claim Payment/Advice

 T-Set: 837 - Health Care Claim

 T-Set: 276 - Health Care Claim Status Request

 T-Set: 277 - Health Care Claim Status Notification

12/16/2019
 Sample EDI 837
16

12/16/2019
 T-Set: 270 - Eligibility, Coverage or
17
Benefit Inquiry
 The EDI 270 Health Care Eligibility/Benefit Inquiry transaction set is used to
request information from a healthcare insurance company about a policy’s
coverages, typically in relation to a particular plan subscriber

 This transaction is typically sent by healthcare service providers, such as

hospitals or medical facilities, and sent to insurance companies, government
agencies like Medicare or Medicaid, or other organizations that would
have information about a given policy

 The 270 document typically includes the following:

 Details of the sender of the inquiry (name and contact information of the
information receiver)
 Name of the recipient of the inquiry (the information source)
 Details of the plan subscriber about to the inquiry is referring
 Description of eligibility or benefit information requested

12/16/2019
 T-Set: 271 - Eligibility, Coverage or
18
Benefit Information
 The EDI 271 Health Care Eligibility/Benefit Response transaction set is used to
provide information about healthcare policy coverages relative to a specific
subscriber or the subscriber’s dependent seeking medical services. It is sent in
response to a 270 inquiry transaction

 This transaction is typically sent by insurance companies, government agencies like

Medicare or Medicaid, or other organizations that would have information about a
given policy. It is sent to healthcare service providers, such as hospitals or medical
clinics that inquire to ascertain whether and to what extent a patient is covered for
certain services

 The 271 document typically includes the following:

 Details of the sender of the inquiry (name and contact information of the information
receiver)
 Name of the recipient of the inquiry (the information source)
 Details of the plan subscriber about to the inquiry is referring
 Description of eligibility or benefit information requested

12/16/2019
 T-Set: 834 - Benefit Enrollment and
19
Maintenance
 The EDI 834 transaction set represents a Benefit Enrollment and Maintenance document. It is used by
employers, as well as unions, government agencies or insurance agencies, to enroll members in a healthcare
benefit plan. The 834 has been specified by HIPAA 5010 standards for the electronic exchange of member
enrollment information, including benefits, plan subscription and employee demographic information

 The 834 transaction may be used for any of the following functions relative to health plans:
 New enrollments
 Changes in a member’s enrollment
 Reinstatement of a member’s enrollment
 Disenrollment of members (i.e., termination of plan membership)
 The information is submitted, typically by the employer, to healthcare payer organizations who are responsible for
payment of health claims and administering insurance and/or benefits. This may include insurance companies, healthcare
professional organizations such as HMOs or PPOs, government agencies such as Medicare and Medicaid

 A typical 834 document may include the following information:

 Subscriber name and identification
 Plan network identification
 Subscriber eligibility and/or benefit information
 Product/service identification

12/16/2019
 T-Set: 835 - Health Care Claim
20
Payment/Advice
 The EDI 835 transaction set is called Health Care Claim Payment and
Remittance Advice

 The 835 is used primarily by Healthcare insurance plans to make payments

to healthcare providers, to provide Explanations of Benefits (EOBs), or both.
When a healthcare service provider submits an 837 Health Care Claim, the
insurance plan uses the 835 to detail the payment to that claim, with the
following details:
 What charges were paid, reduced or denied
 Whether there was a deductible, co-insurance, co-pay, etc.
 Any bundling or splitting of claims or line items
 How the payment was made, such as through a clearinghouse

 The 835 is important to healthcare providers, to track what payments were

received for services they provided and billed

12/16/2019
 T-Set: 837 - Health Care Claim
21

 The EDI 837 transaction set is the format established to meet HIPAA requirements for the electronic
submission of healthcare claim information. The claim information included amounts to the following, for a
single care encounter between patient and provider:
 A description of the patient
 The patient’s condition for which treatment was provided
 The services provided
 The cost of the treatment

 The 5010 standards divide the 837 transaction set into three groups, as follows:
 837P for professionals
 837I for institutions
 837D for dental practices. The 837 is no longer used by retail pharmacies.

 This transaction set is sent by the providers to payers, which include insurance companies, health maintenance
organizations (HMOs), preferred provider organizations (PPOs), or government agencies such as Medicare,
Medicaid, etc. These transactions may be sent either directly or indirectly via clearinghouses

 Health insurers and other payers send their payments and coordination of benefits information back to
providers via the EDI 835 transaction set

12/16/2019
 T-Set: 276 - Health Care Claim Status
22
Request
 The EDI 276 transaction set is a Health Care Claim Status Inquiry. It is used by healthcare providers to verify
the status of a claim submitted previously to a payer, such as an insurance company, HMO, government
agency like Medicare or Medicaid, etc.

 The 276 transaction is specified by HIPAA for the electronic submission of claim status requests. The
transaction typically includes:
 Provider identification
 Patient identification
 Subscriber information
 Date(s) of service(s)
 Charges

 Submitting a 276 status request to a payer is the first step in the claim status request/response process. The
payer provides the requested information in response to the 276 request using a 277 Claim Status
Response transaction

 The use of EDI 276 inquiries, along with the 277 response, replaces the manual process of managing
payments and claims. By submitting the inquiry via EDI with the 276 transaction, administrators can receive
the information more quickly and with little or no manual intervention

12/16/2019
 T-Set: 277 - Health Care Claim Status
23
Notification
 The EDI 277 Health Care Claim Status Response transaction set is used by healthcare payers
(insurance companies, Medicare, etc.) to report on the status of claims (837 transactions)
previously submitted by providers

 The 277 transaction, which has been specified by HIPAA for the submission of claim status
information, can be used in one of the following three ways:
 A 277 transaction may be sent in response to a previously received EDI 276 Claim Status Inquiry
 A payer may use a 277 to request additional information about a submitted claim (without a 276)
 A payer may provide claim status information to a provider using the 277, without receiving a 276

 Information provided in a 277 transaction generally indicates where the claim is in process,
either as Pending or Finalized. If finalized, the transaction indicates the disposition of the claim
– rejected, denied, approved for payment or paid

 If the claim was approved or paid, payment information may also be provided in the 277,
such as method, date, amount, etc. If the claim has been denied or rejected, the transaction
may include an explanation, such as if the patient is not eligible

12/16/2019
 HIPAA 4010 to 5010 conversion –
24
what are the changes?
 Version 5010 compliance date – January 1, 2012

 With the Version 5010, the formats currently used must be

upgraded from X12 Version

 Formats that must be upgraded include:

 Claims (837-I, 837-P)
 Remittance Advice (835)

 No job requirements currently related to 5010 conversion. But there

could be projects related to fixing any issues related to the 4010 –
5010 conversion projects implemented earlier

12/16/2019
 ICD-9 to ICD-10 conversion
25

 ICD-9 follows an outdated 1970's medical coding system which fails to capture detailed
health care data and is inconsistent with current medical practice. By transitioning to ICD-10,
providers will have:
 Improved operational processes by classifying detail within codes to accurately process payments and
reimbursements
 Detailed information on condition, severity, co-morbidities, complications and locations
 Detailed health reporting and analytics such as cost, utilization and outcome
 Expanded coding flexibility by increasing code length to seven characters

 Important Dates:
 January 1, 2012 - ALL providers must upgrade to Version 5010 in order to accommodate ICD-10
codes
 October 1, 2013 - ICD-10 codes must be used for all procedures and diagnosis on and after this date.
Claims with ICD-9 codes for services provided on or after October 1, 2013 cannot be paid. This was
extended to 2014 I guess (not sure)

 No requirements currently related to ICD-10 conversion. But there could be projects related to
fixing any issues related to the ICD-9 – ICD-10 conversion projects implemented earlier

12/16/2019
 Care Management/
26
Case Management
 Care management is a set of activities intended to
improve patient care and reduce the need for
medical services by helping patients and caregivers
more effectively manage health conditions

12/16/2019
 Care Management
27

12/16/2019
 CM – goals and objectives
28

 The overall goals of care management are:

1. to optimize the patient’s ability to take care of himself or herself; and
2. to identify and coordinate needed resources and support.

 Steps:
1. Patient identification and comprehensive assessment:
 Patients are identified through direct referrals, by mining administrative claims data (e.g., risk stratification tools, frequent
hospital and emergency room admissions), through screenings and assessments, and through chart reviews that identify
gaps in care.
2. Developing an individualized care plan:
 The health care team — including the care manager, primary care provider, patient and family/caregiver — agree on
goals in a care plan.
3. Care coordination:
 The care manager ensures the patient’s care plan is implemented, communicating and coordinating across providers and
delivery settings. Care manager interventions are identified and documented.
4. Reassessment and monitoring:
 Patient’s progress is monitored toward goal achievement on an ongoing basis, adjusting care plans, as needed.
5. Outcomes and evaluation:
 The care manager uses the quality metrics (discussed in Modules 7 and 10), assessment and survey results, and utilization
of services to monitor and evaluate the impact of interventions.

12/16/2019
 CM Projects
29

 Projects related to System replacement and Up

gradation of analytics capability

 Vendors – McKesson, Landacorp, ZeOmega,

Medecision, TriZetto, Click4Care, CaseNet, DST
Health Solutions, ikaSystems

12/16/2019
 Medicare
30

 Medicare is a Federal health insurance program that pays for hospital and medical care for elderly and
certain disabled Americans

 Eligibility:
 An individual must either be at least 65 years old, under 65 and disabled, or any age with End-Stage
Renal Disease (permanent kidney failure that requires dialysis or a transplant.)
 In addition, eligibility for Medicare requires that an individual is a U.S. citizen or permanent legal
resident for 5 continuous years and is eligible for Social Security benefits with at least ten years of
payments contributed into the system

 The program consists of two main parts for hospital and medical insurance (Part A and Part B) and two
additional parts that provide flexibility and prescription drugs (Part C and Part D)
 Medicare Part A, or Hospital Insurance (HI), helps pay for hospital stays
 Medicare Part B is also called Supplementary Medical Insurance (SMI). It helps pay for medically
necessary physician visits, outpatient hospital visits, home health care costs, and other services for the
aged and disabled
 Medicare Advantage Plans (sometimes known as Medicare Part C, or Medicare + Choice) allow users
to design a custom plan that can be more closely aligned with their medical needs
 In 2006, Medicare expanded to include a prescription drug plan known as Medicare Part D

12/16/2019
 Medicare contd.
31

 Supplemental coverage for medical expenses and services that are

not covered by Medicare are offered through MediGap plans

 Who pays for Medicare?

 Payroll taxes collected through FICA (Federal Insurance
Contributions Act) and the Self-Employment Contributions Act are
a primary component of Medicare funding. The tax is 2.9% of
wages, usually half paid by the employee and half paid by the
employer

 Moneys are set aside in a trust fund that the government uses to
reimburse doctors, hospitals, and private insurance companies.
Additional funding for Medicare services comes from premiums,
deductibles, coinsurance, and copays

12/16/2019
 Medicaid
32

 Medicaid is a means-tested health and medical services program

for certain individuals and families with low incomes and few
resources. Primary oversight of the program is handled at the
federal level, but each state:
 Establishes its own eligibility standards,
 Determines the type, amount, duration, and scope of services,
 Sets the rate of payment for services, and
 Administers its own Medicaid program.

 Who is eligible for Medicaid?

 Each state sets its own Medicaid eligibility guidelines. The program is
geared towards people with low incomes, but eligibility also depends on
meeting other requirements based on age, pregnancy status, disability
status, other assets, and citizens

12/16/2019
 Medicaid contd.
33

 Who pays for services provided by Medicaid?

 Medicaid does not pay money to individuals, but operates in a program that sends
payments to the health care providers. States make these payments based on a fee-for-
service agreement or through prepayment arrangements such as health maintenance
organizations (HMOs)
 Each State is then reimbursed for a share of their Medicaid expenditures from the Federal
Government

 States may impose nominal deductibles, coinsurance, or copayments on some

Medicaid beneficiaries for certain services. However, the following Medicaid
beneficiaries must be excluded from cost sharing:
 Pregnant women,
 Children under age 18, and
 Hospital or nursing home patients who are expected to contribute most of their income to
institutional care.
 All Medicaid beneficiaries must be exempt from copayments for emergency services and
family planning services.

12/16/2019
 Consumer-driven health care (CDHC)
34

 Refers to third tier health insurance plans that allow members to use Health savings accounts
(HSAs), Health Reimbursement Accounts (HRAs), or similar medical payment products to pay
routine health care expenses directly, while a high-deductible health plan (HDHP) protects
them from catastrophic medical expenses

 High-deductible policies cost less, but the user pays routine medical claims using a pre-funded
spending account, often with a special debit card provided by a bank or insurance plan. If the
balance on this account runs out, the user then pays claims just like under a regular deductible.
Users keep any unused balance or "rollover" at the end of the year to increase future
balances, or to invest for future expenses

 Examples:
 Flexible spending account (FSA)
 Health Reimbursement Account (HRA)
 Health savings account (HSA)
 High-deductible health plan (HDHP)
 Medical savings account (MSA)
 Private Fee-For-Service (PFFS)

12/16/2019
 Flexible spending account (FSA)
35

 A flexible spending account (FSA), also known as a flexible spending arrangement,

is one of a number of tax-advantaged financial accounts that can be set up through
an employer


 An FSA allows an employee to set aside a portion of earnings to pay for qualified
expenses, most commonly for medical expenses but often for dependent care or
other expenses

 Money deducted from an employee's pay into an FSA is not subject to payroll taxes,
resulting in substantial payroll tax savings

 Before the Affordable Care Act, one significant disadvantage to using an FSA is
that funds not used by the end of the plan year are lost to the employee, known as
the "use it or lose it" rule. Under the terms of the Affordable Care Act, an employee
can carryover up to $500 into the next year without losing the funds

12/16/2019
 Health Reimbursement Account (HRA)
36

 Health Reimbursement Accounts or Health

Reimbursement Arrangements (HRAs) are Internal
Revenue Service (IRS)-sanctioned employer-funded, tax-
advantaged employer health benefit plans that
reimburse employees for out-of-pocket medical
expenses and individual health insurance premiums

 Health Reimbursement Accounts are funded solely by

the employer, and cannot be funded through employee
salary deductions. The employer sets the parameters
for the Health Reimbursement Accounts, and unused
dollars remain with the employer

12/16/2019
 Health savings account (HSA)
37

 A health savings account (HSA) is a tax-advantaged medical

savings account available to taxpayers in the United States
who are enrolled in a high-deductible health plan (HDHP)

 The funds contributed to an account are not subject to

federal income tax at the time of deposit. Unlike a flexible
spending account (FSA), funds roll over and accumulate year
to year if not spent

 HSAs are owned by the individual, which differentiates them

from company-owned Health Reimbursement Arrangements
(HRA)

12/16/2019
 Healthcare Data warehousing
38

 Data warehouse is critical in healthcare industry for reporting and

analytics needs

 Data from the operational systems handling Claims, Groups,

Membership, Eligibility etc is transferred to the data warehouse on a
daily basis

 It is a normal practice to use the data warehouse for both internal

and external reporting needs unless the real time data in required

 Data dictionaries provide information related to the tables and the

structure of data storage in the warehouse

12/16/2019
 Data warehousing contd.
39

Operational
systems

Staging
area

Reporting (Internal and external) Data

and analytic needs warehouse

12/16/2019
 Data warehousing requirements
40

 Reports
 Understanding the user requirements
 Designing the layout
 Defining the elements in the report – business definition
without any ambiguity
 For example, ‘Member ID’ – define whether it is internal or
external Member ID and the number of digits etc.
 Other info
 Frequency of reporting
 Internal or external
 Recipients
 Mode of delivery

12/16/2019
 Data warehousing requirements
41

 Analytics – Third party vendor applications are used by the clients to

enable their analytic capabilities

 Role
 To understand the client requirements related to the analytic capabilities

 Coordinating with the vendors on how they would be delivered

 Coordinating with tech folks to provide the vendor with the data required for
analytics

 Explore if the vendor’s standard capabilities could be leveraged for the client
needs

 Else customize to meet client needs

12/16/2019
 Data warehousing requirements
42

 Impact assessment and remediation - Lot of projects in this

area

 The requirements arise as a result of any project

implementation with the operational systems that impact the
data flow to the warehouse

 It leads to remediation of the data flow, and all the reports

and analytics dependent on them

 These jobs need an understanding of the business process

and the data flow as well

12/16/2019
 The Affordable Care Act of 2010
43
(ACA) – Obamacare – What is it?
 The Affordable Care Act is the nation’s health
reform law enacted in March 2010

 It contains numerous provisions that will

 expand health coverage to 25 million Americans,
 increase benefits and lower costs for consumers,
 provide new funding for public health and prevention,
 bolster our health care and public health workforce
and infrastructure,
 foster innovation and quality in our system, and more.

12/16/2019
 The Affordable Care Act of 2010
44
(ACA) – Obamacare – impacts
 Insurance companies will make some changes as a result of Obama Care

 For example, companies can no longer exclude people with pre-existing conditions, and
children will be allowed on their parents’ policies until age 26

 There are some lesser-known provisions that will impact insurance companies, like the medical
loss ratio, for example. The medical loss ratio provision states that 80% of an insurance
premium must go to actual paying of coverage and only 20% may be used for overhead,
marketing and profit

 The good news is that insurance companies avoided the worst possible outcome, which is being
subject to market reforms and not having the new, young, healthy people requiring health
insurance. With a health insurance mandate, the young and healthy demographic that were
previously uninsured will now buy insurance, balancing out the good risk and the bad risk for
insurance companies

 Boards of insurance companies need to be quite focused on implementation of market place

and deadlines in place for 2014

12/16/2019
45 12/16/2019
 Claims processing flowchart
46

12/16/2019
 Claims processing flowchart
47

12/16/2019
 HIPAA 4010 to 5010 conversion –
48
what are the changes?
 A physical street address must be reported for the billing provider’s service address. A PO Box address will not be accepted
 Only a provider Pay-to address can be a PO Box address
 Require 9 digit zip code
 Enhanced NPI Reporting rules
 Support for atypical providers (taxi drivers, carpenters and personal care providers)
 837I - Expansion of the number of Diagnosis Codes
 837I - Present on Admission Indicators can now be reported for diagnosis codes
 837P - Supports Ambulance related billing
 837P - Allows reporting of Anesthesia units only in minutes
 Coordination of Benefits – clarification and enhancements on how to report primary, secondary and tertiary payers for claims
transactions
 Remaining Patient Liability can now be calculated for claims transactions
 Adjustment reporting has been clarified now allowing for the Primary payer claim level adjustment codes reported in the 835
to be sent to the Secondary payer
 835 - New sections have been added to organize the payment remittance process
 835 - Claim splitting has been clarified by specifying the use of the MIA or MOA segments
 835 - Segment has been added for Lost and Reissue Payment to prevent recreation or retransmittal
 of a remittance
 835 - Encounter reporting has been clarified

12/16/2019
 Plans Comparison
49

12/16/2019
 FACETS – Claim Submission Software
50

12/16/2019
 List of FACETS Table
51

12/16/2019
 FACETS Tables
52

12/16/2019
 FACETS
53

12/16/2019
 FACETS
54

12/16/2019
 MEDICARE
55

12/16/2019
 MEDICARE
56

12/16/2019
 MEDICARE
57

12/16/2019