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hi everyone this is a brief overview of the healthcare domain and how a business analyst would play a part in it we will be going through a couple of basic concepts like EDI transactions basic terminologies our claim is processed the plain work flow how it how it starts how it starts as a claim its processed and finally the claim gets made these are some of the concepts that we'll be covering and let's start off with a couple of healthcare terminologies so we're going to start with a couple of terminologies that we are familiar with the first one is subscriber so a subscriber is an individual who who meets the health plans eligibility requirement and who can enroll in a health plan and he or she accepts the financial responsibility for any premiums or co-payments coinsurance or deductibles so the next term is number member is a person who is eligible to receive or is receiving benefits from an HMO or an insurance policy this this includes those who are enrolled or subscribed and their eligible dependents so a subscriber is a person who who gets these benefits whereas a member gets enrolled and also his his dependents are covered so person becomes a member of a health care plan whereas the subscriber it's just an individual the next term is provider so provider is a supplier of healthcare services like hospital nursing home lab or physician so anyone who provides you with healthcare service is called a provider the next term is claim so a claim is is like a detail invoice that your health care provider so like we talked about in the earlier term a doctor or clinic or hospital this this claim is is like an invoice that's that's being sent to the health insurance inter health insurer who is your insurance provider and this invoice will exactly show what services you you perceive to remember ID your name your demographics everything that's needed to actually pay out that thing and the next others coinsurance so coinsurance you might have come across this term this is a form of cost-sharing between the member and the insurance company so you and the health insurance provider so if you're insured you pay a percentage of the cost of covered medical services and the insurance company pays percentage so usually it's like after you cross a certain amount of money and after you pay it out the insurance company won't usually pay you the entire amount of money it's like we'll pay 90% and you have to cover the remaining 10% now I wanna include another word here it's called out-of-pocket maximum so for example the out-of-pocket maximum is is like ten thousand dollars you are only liable to pay ten thousand dollars so if your claim amount is twenty thousand dollars the ten percentage that I mentioned earlier would be applicable only for the ten thousand dollars out-of-pocket maximum after that the claim usually covers the entire charges that you have to incur the next one is co-payment so co-payment again is form of cost-sharing where danger person pays a specified flat amount per unit of service so for example if you are visiting a doctor and the doctor charges 200 bucks the co-payment is going to be $30 so you only pay $30 the remaining $70 is being taken care of by the health insurance that you have and the next term is deductible our deductible is a certain dollar amount that you must be before your health insurance coverage actually begins to cover your medical expenses it might be $500 per year and once you've got cross the $500 then the coinsurance applies applicable and the plan then proceeds now getting a bit more technical so the next word is EDI this the definition is electronic data interchange now this is applicable in different industries and basically this is just a computer to computer exchange of business documents in a standard electronic format between business partners so basically it's an encrypted way of selling information from one organization to another because the data that you're transmitting is sensitive the next term is going to be personal health information or B h-hi now pH is also referred to as protected health information so this generally refers to demographic information like your age your location your first name your last name your medical history the tests and lab results the insurance information and any other data that a healthcare professional collects to identify an individual and determine appropriate care now this is protected information because this is confidential and it is it should be only accessible by you so when you're transmitting this information from one organization to another they make sure that's that it's encrypted and it doesn't get leaked the next one is going to be HIPAA so HIPAA is Health Insurance Portability and Accountability Act of 1996 because that was the year that it was introduced so HIPAA is nothing but the law that sets standards regarding the and privacy of a person's health information this has a really buy things but we are just going to talk about typing one and I think two because these titles are more apply more to health care claims processing so the first type will is called health insurance reform now this is a title that protects health insurance coverage for individuals who lose or change jobs so suppose you lose your job or you change your job the time interval should be covered by your health insurance and this also prohibits group health plans from denying coverage to individuals with specific diseases and pre-existing conditions and from setting lifetime coverage limits so that basically means that if you have a pre-existing condition that should be covered by your health insurance plan and that is along moving on too tightly to tied it to his HIPAA administrative simplification so this tiding basically says that it establishes national standards for processing these health insurance transactions so it basically requires your healthcare organizations to implement secure systems to transmit this health data from one organization to another or to the state the next term is coordination of benefits so this is a process where if an individual has to group health plans the amount payable is divided between the two plans so to combine the coverage amounts do not exceed 100% of the charges so this basically means that if the person has two plans it shouldn't take more than 100 percent of what the person should be actually getting the next term is ICD codes so we're going to talk about icd-10 first so I see he just means international classification of diseases and previously the question was icd-9 and after the turbo first of 2015 icd-10 was introduced and it's basically a clinical cataloguing system that went into effect and this basically comes for modern advances and clinical treatment and medical devices so these codes actually offer many forms of classifying options compared to icd-9 so icd-10 actually covers about 68,000 medical devices and healthcare health conditions whereas icd-9 covers about 13,000 and hl7 so hl7 is it provides a framework it's it's it's help level seven and this provides a framework where the exchange the sharing and retrieval of electronic health information this is big this basically follows a certain structure and these standards are basically how information is defined and communicated from one party to another so it sets what language to use what the data structure of the file should be what what the data type should be so this basically helps the integration between different systems the last term is ax C X 12 so ASC is created Standards Committee so it's it's an organization and it was chartered by the American National Standards Institute and it develops and maintains these x12 EDI content and establishes standards for it so these EDI files are basically X and all schemas and the organization or committee they actually need up in mind how these standards should be how the file structure right so moving on to the next slide so in this slide we'll be looking at how the claim is processed so starting off a person goes to a healthcare provider so the healthcare provider is the hospital or doctor or clinic so the the member actually has a valid health insurance and he will visit an in-network healthcare provider or a doctor for a particular service now this healthcare provider provides this service to the member and then we healthcare provider submits a claim or an invoice to the health insurance provider so this is basically a document that gives you details about the patient what service was ever seen and this is sent in an encrypted way Dulli an insurance provider now the insurance provider actually processes these claims he makes sure that there are no data errors or there are no conflicting data from previous claims and make sure that the correct amount is paid it's after this is played the an explanation of benefits is provided to the member so this basically states that okay this was the service that you receive and this was the one that we paid this is why we don't cover some of the costs so it's basically information for the member then the health care provider will send a bill to the member if a balance needs to be paid so if there's 100 bucks that can be covered by the health care divider the the amount that is sent to number and the member has to pay that so that's a brief overview of how a claim is processed now if you look on the right we have a flow chart and these four functionalities at the top transaction management risk management business intelligent content management these are some of the payer services so a pair is nothing but someone who reinforces at number four the cost of the health service now these systems are in place to make sure that the claims curtly brought correctly processed and correct amount is paid and these services can be broken down into the starts of the Member Services and clarifies it in other isn't known it goes to provide provider tree elektra and showing where it makes sure that the correct provider is being sent that particular thing it goes together eligibility where the eligibility team checks whether the patient is qualified for sealing that claim or receiving that money and how much should he be given it then goes on to claims administration where these claims are segregated into different departments and based on that it sank two different different parties for profit after this is done the transactions are verified and they are repriced if needed and the next step is adjudication where the claims are processed this is where most of data mining and data science apply because this is the place where they don't mind how much money should be paid and if there are issues with previous claims and all that then this is settled an explanation of benefits is sent to the lender and all this information is being stored in a tier breeze moving on we'll briefly be talking about health care plans and health care plans are basically of two types so meshow and government to start off with commercial commercials classified into immediately classified into five categories the first commercial plant is a preferred provider organization or PPO so a BPO provides more flexibility when you're picking a doctor or a hospital they feature network of providers but there are fewer restrictions on seeing on network providers traditionally your PP O insurance will be if you see a non-network provider although it may be under lower it so it just basically means that the PPO would allow you to see members that are not in their network compared to a plan that will we'll be discussing in a few minutes and the key features are that you can see any doctor or specialist that you like without having to see a preferred care provider now a preferred provider is just a doctor that you have to visit to assess your condition and the PCP actually didn't - what kind of treatment should be given to you and if a specialist is needed to provide a service for you he refers it and so you cannot see a doctor or go to a hospital outside the network and you may be covered however your benefits will be better if you stay in the network now an EPO is an exclusive provider organization this is a hybrid plan but the healthcare providers must be seen within a predetermined network and it just tells you that this is the network we'll be using and you should be getting services from this network not outside of it the next plan is a cello now HMO gives you access to certain doctors and hospitals within a network it's it's the exact opposite of PPO and these this network is basically made up providers and the rates are usually lower if the person if the member actually visits the providers within the network so supplemental insurance so supplemental insurance is anything that covers the amount of money or the procedures that aren't covered by your reinsurance theater PP or an EP or a hitch pin and Medigap especially basically an insurance that you get to cover healthcare costs such as copayments deductibles if you're traveling outside the US so moving on we'll talk a bit about HIPAA so HIPAA is again like I mentioned health information Portability and Accountability Act they set standards for automating business processes of claims and handling situations and they define certain criterias to make sure that the claims are processed and the information is handled in a secure way to make sure that the information isn't being accessible by people who shouldn't be accessing the next topic we're going to talk about is HIPAA transactions now hippest transactions are basically when we move on to the next slide HIPAA transactions or EDI transactions are basically files or XML schemas that are used to transfer the transfer information from one of organization to another so be brief over here would be 270 file is used to request information from a health insurance company about policies coverage typically that's related to a particular plans subscriber and 271 file is used to provide information about these policy coverages doing the specific subscriber or a person who is actually seeking with the medical service so this is a response that's being sent for it to 70 the next file is an 834 or benefit involvement file and this basically represents a benefit enrollment and maintenance document and it's used by employers or people who actually provide you with insurance to enroll them in a particular benefit plan and some of the information includes subscriber name identification the name of the network subscriber eligibility etc the next file is going to be an 835 so 835 is used by health insurance plans to make payments to health care providers and it also includes information about the benefits that the member received and when the health service provider actually submits and 8:37 the insurance plan uses an 835 to detail the payment to that plane and this 8:35 file is important because it tracks what payments we'll see for that particular service the next file is going to be an 837 so in any 37 is just a format that should meet HIPAA requirements and it's a standard health care claim file this just gives you a description of the patient the condition and services received and the cost of the treatment and these 837 files are supplied in the three groups professional institutional and dental practices and 276 file is used by healthcare providers to verify the status of a claim submitted previously to appear such as an insurance company and 277 file is used by health care prayers to the board on the status of that train so 277 is a response to a 276 and we briefly touch about the Affordable Care Act plan or Obamacare this was enacted in much our 2010 so the intention of the plan to make positive make sure that most people are covered and they get more benefits they have to pay less money for the benefits that they are seeking and the the initiative actually funded the implement and it provided a cheaper means of coverage to people to a lot of people and this basically increased employment and build our infrastructure for these providers and this also made sure that companies can no longer exclude these patients with conditions with pre-existing conditions which we earlier covered in title 1 and their children will be covered under the plan if they are 26 or younger will briefly touch about the eligibility and benefits so patient eligibility is a section of healthcare claims processing where the equations eligibility and benefits are verified do every pilot so if person if a member actually seeks a provider he goes with the insurance information that he's been that he has and this insurance plan is actually analyzed to make sure that the basin patient is eligible to receive those benefits and the eligibility and benefit gives you the membership verification how long the plan duration is how long will the patient be covered the the different services that the patient can receive within this plan the co-payment the deductibles the coinsurance all that all that information so this actually gives information to members and providers because providers are the ones giving you the service and the information basically includes identifiers like the patient information demographics first name last name the condition is is there is there a group ID for it but the name of the plan is who they ask healthcare provider is the the dates during which the the actual plan is valid mmm the co-payment for that particular service mean deductibles the out-of-pocket maximum like we talked earlier has that person actually reached that unknown coinsurance like we discussed earlier are there any limitations for this particular healthcare plan so is there a service that the patient wouldn't be covered and pre-authorization is basically a service that makes sure that the patient meets certain criteria before the services are administered to the patient and it gives you information about whether the person is allowed to actually receive those benefits that the health care plan promises to the so we needed skip to topics here the extent explodes standards and the 401 go to file or conversion so external external standards are basically keeper standards that make sure these conditions whatever whatever information goes into these files that we discussed earlier are of a certain syntax and 401 or 501 or I just HIPAA standards so follow on for what the previous one which covered a certain number of conditions and these conditions are basically presented by code so if it's diabetes it's something like e 42 so the claim file doesn't actually contain contain information that says the patient has diabetes just says the patient information like first name last name and the code for that particular condition and 501 o is basically a code that was implemented as an update for 401 4 and the conversion process was put in place so people who were using the older 401 know version for example if 42 will be converted into a 49 to make sure that it responds with the 501 standards so that is basically a brief overview of the health care system in America and it's basically information in that would get you started about the health insurance to mean how claims are processed and other details