Electronically Signed Medical Claim Made Easy

Electronically signed medical claim

okay so let's move on here so some of the storms that we use in healthcare there's a lot of terminology Healthcare is a never-ending thing as things go on things change there is there is always some kind of neutron coming into the market and so it's a never-ending their face you know I am silly only I am I am ten years into this health care market I am still learning new terminology every day so no matter what it is but there are some terms we definitely use in the marketplace we definitely use them you know when I say marketplace you know I'm talking about car insurance industry and health insurance industry uses a very very common terms here so on the first bullet point here the patient okay so we don't call patient patients in the health insurance industry we call a patient as a member so the membership data will come through what we call it enrollment data so membership membership data enrollment data that means the same thing the 8:34 what is this this is the EDI transaction so there is a file format that yeah that is used to send membership data from one system to another system and and that file format is actually Colin 834 and the second bullet point we talked about dr. obviously we don't live for doctors and doctors in in the health insurance industry we call it as provider provider data and I wanna shake providers so two terms a difference you know patient is a member dr. is a provider and why what would you call it in a patient is a member because you're where your pain has been premium in order for for UnitedHealth to cover for your health insurance and we and we call you as a member you are a member of the United house you are a member of Aetna you're a member of some of interest the doctor is a provider provider is it doesn't matter which day the some providers have contracted agreement with some major as guesses but most of the time doctors took their patients from all different payers meaning Adnan United Health any health insurance plan the next minute point is hospital the doctor within hospital sometimes you know we basically refer as hospital or institution so that there are two terms that we use in the hospital setting we use inpatient and outpatient settings now one good example of an inpatient is and somebody had a baby and you have to stay in the hospital for one week so there is an area date and there is a discharge for example date you got admitted on Monday as a baby and you got discharged on Friday so there is technical and it is discharge it and that's what you call it as inpatient you're actually singing in the hospital for one week outpatient setting I gave you an example just now so you went to the hospital to get your heart checked the still be difficult to the clinics and the doctor screening don't have all the equipment Hospice bye-bye equipment the doctor with the providers day hey wanted to go to this clinic and get your heart set and they would actually refer you to the hospital and you go there a little money and we'll be done like my big day that would be enough fishing setting the next bullet point we talk about pairs we have different kind of players we have has now united health ADC health insurance there are so many health insurance companies market and so we you can actually go to a list of all those stairs so why do we call pairs because we pay for your health insurance and you pay the premium a member pays the premium and we pay for your cousin so for example you don't go pay $500 a week every time you go and visit a doctor just because you're paying a premium off from $600 a month we covered you for all the health insurance out of the health care all the doctor with it the cost is very very look if you don't have health insurance I mean I had a family member who had a baby without her health insurance every time you go to visit they actually play thousand dollars to the doctor because your maternity was power at that time he actually paid thousand dollars every business so what if you have a future if you have health insurance you would have $1,000 a month $2,000 for every reason maybe in twelve maybe hundred dollars hundred fifty dollars so that's a baby no because we painted for the arrest of the cop okay the moving on to the next part which is that HIPAA transactions this is where we are so the hippo transactions are basically the EDI transactions as the what we use nowadays health insurance industries are actually moving into people transactions a lot a lot of manual processes proprietary file layout we've all done so so this is the Health Insurance Portability affordable acts as part of this the husband she was quoted in the Affordable Care Act every health insurance company must use a standard file format when they are sending a file from one system to another system that's what we call HIPAA transactions then there was 40 10 a transaction there was 40 10 they were spotted in a now it's all 50 10 and so all the transactions are 50 and compliant so these are all different versions of yes so again so the paper transactions are the five barmen this is the electronic data into EDIS for file formats it's a very standard format that we use in the marketplace I mean the health insurance market where you have to use this format in order for you to send data from one system to another system okay so this move on here so 837 hi 837 P you have 276 and 277 so these are on the different file formats and the different purpose so 837 I is an institution same format used for inpatient and outpatient setting and 837 P is a professional training file format used by the doctors the doctor is standing there clinging to health insurance company you have to use 837 P for all the doctor visits and such if you went to that example that I gave this company had it basically and obviously the hospital needs to get paid so they would actually send a new patient came to the United cells so the way the standard dealer is basically is using that 837 hi and then you have their outpatient just well so somebody went to go check their heart you will use the a 37 hi but the outpatient data actually goes there so there is pharmacy data there is dental data we're not going to cover that with this one 18 or 80 percent of the market is actually focused on 837 a 35 to 36 277 835 think of this as an electronic check it's called a remittance advice so doctors get mustard paste so once you process the claim we actually set in a 30 by to the payment gateway so you're actually getting your pages to think of this as an electronic something like a wire transfer I want to say it's like dancing wire transport but it's very closely related to that because that has pain elimination steps then you have Tuesday six and 277 that's the pain status your question response somebody wants milk and status or where we are actually dependent is it paid what's happening with my pain now you can send it to service Victor to film develop it is to 70 to 71 there's to 78 there's a lot of transactions out there and because as we go to this demo I will actually show you an example and I would actually walk you through a clean life cycle turning partners or clearing houses so think of this as a as technology-based companies who specialize in the I tried such technical companies that their technology come to specialize in EDI transactions so there's system a so say for example doctor's office be spending and say for example a a major heart hospital ascending a claims to deny the death in Iverson so they in between the United Health and this major hospital they are trading partners sitting in between our trading house these are technical organizations to focus on EDI transactions they work on cleaning up the data they massage the data they help the pair's making sure the format is validated all a transaction is up to the standard and all of that and three colors in more detail as we go through our demo as we go through the paints life cycle in the next few minutes and you have this clear life cycle how does the game get processed so there are different data to obtain you have tend you have paint you have denied you have on hold you can sometimes saying there's different different statuses as well the most generic stented statuses that we see here is and they denied and hold so every system has their own statuses nowadays as you can see try there are some tools in system faster than Q and X T then they follow the same same methodology they have different statuses and I see there is the HP product called Netherlands and they have a different sense it's dependent on the system but the turns are very generic you know the purpose is building pavement is play this game in this place denied means extraneous tonight friend it in this game is bended thank this pretty straightforward this is the terms are different explanation of payment eel bees and neo p.m. the federal government has mandated by law that every health insurance company once you go to the doctor with it you must send a exclamation of payment and explanation of benefits to all the members so I'm sure most of you have health insurance you get a lot of mail from home you know I want to say United health as now whatever the payer you have do you get a lot of mail from from the health insurance companies because you just visited a doctor and you get a meal you're just so if you open a letter on the right hand side top corner they would actually say explanation of payment or explanation of benefit my name's Ben so you went to the doctor and this is what we this is this is how much copay you paid and this is how much we pay to the doctor and if there is any balance this such they would actually put that there so you'll be they would actually explain you about the benefits if you have measured adjusted or not if you have not this is what you think that if you are mature deductible you don't need to pay and there's a lot of technical details in there so we can go through that in much more detail but the purpose really here is to understand the real need of an t OB and immediately it's just a letter that you get in mail explain the payment of your last visit to the doctor go to the Opera and also explaining those benefits so these two letters are different okay all right so before I start so I wanted to go so this is this slide actually focuses on health insurance claims lifecycle so how does the typical health insurance company get the train okay so I put this diagram together in the slide show so I'm going to walk into this scenario so please be patient here it is this may be a little complicated for you again so let me and so this is the health insurance electronic claims entering process and our that the electronic claims we use HIPAA transaction okay and all right so there are a few things that we need to you know in a business analysis zone we call this a four million diagram as I put it there similar diagram so it can you can see on the differences how it can gets process from one stage to another stage from an internal perspective okay and so we have members the members are nothing but you and me right so I am a member of Blue Cross you are a member of United Health some of these some other opportunity member apat so people who pay people who pay premiums are there the members basically and the next one you are providers remember what I've been providers are doctors by the wires are also hospitals so we consider providers at hospitals but we have providers you have hospitals so for this diagram I put it providers and hospitals under one simulate and just you know you would understand this when I walk you through this video and the next part is the trading partners or clearinghouse and trading partners like that are companies who are technology companies who specialize these in and Alban electronic transactions they help health insurance companies to massage the data package the data is so it can be easily consumed so these are all technical comfortable so one example is try better try that are also actually stripe as a trading partner we have to have you have envy on MG on is also a clearinghouse at a trading partner who specialize within the payment transactions like 835 and such as the work for a company policy has the little very small company based in the u.s. so these companies specialize in video I transactions they take it to take the EDI transactions from the doctor's office to the hospitals that they'll massage the data and this is the health insurance companies all right so now we have health insurance companies here so there are different health insurance companies of United Salvia Blue Cross you have eyes now you have so many companies out there who provide health insurance okay so in this scenario so I'm actually going to walk through a couple of scenarios here the one would be an individual member I am paying in my own health issues let's take me as an example I'm a consultant I pay my own health insurance the two United Health and I pay from my pocket on a monthly basis with the I don't work for any employer I work for myself so I pay for my own has been transfers for me okay now if you see the scenario here so we have the member so that's me the blue med and and we have a doctor so this is my doctor who I go to and I have turning placards so remember this company is a major technology company the technical hub would actually get a lot of data practices and they send it to travel insurance companies so you have United States the well point four point as the Humana so there's so many companies out there who actually provide health insurance and health insurance to go there and buy a future Darla okay so in the next part is basically your your clean distance like patent is one system you have qxc and you have metal so these are different pain systems that are available in the market we have practiced Imperial XE with this try settle products are tried they're the proprietary products these are pains education systems very specifically used for certain markets before the TLX t is used more on the Medicare side the government side with position a brand new product on the tripe data side you have matter grams matter on display to your HP adheres tactic person this is again another claims education system but remember the clear gains adjudicated the system where we actually adjudicate a claim adjudicated meaning process a claim so in this scenario that I'm going to walk through 50 I am the individual policy holder of United Health united health systems dying a member of this united tell i'm going to pay everything from my pocket meaning I paid my own health insurance the United Health and I'm not part of I don't work for any entire and in this scenario I am actually going for a doctor visit so I have a doctor very close by doctor let's just say John is my doctor okay so he's my PC because my primary care physician and I go to this doctor so in this example it's because of the season the spring season I am actually going to get a flu shot okay I'm actually going to get it from each other numbers my doctors and so the first test I will eventually that my doctor's visit so I go to the doctor to get a flu shot the first thing happens is the administrative assistants at the doctor's office will look at my insurance card she or he will get my insurance card and she'll I should look at him you can look me in their system and making sure I am still active I am paying my premium again in this case my doctor accepts United Health members so that's exactly - some doctors accept certain insurance research our assumption for this is basically my doctor accepts my United Health in shift so I went to the doctors to get his flu shots I where the administrative assistant at the doctor's office verified my insurance it's all good I had to pay $25 copay and I paid that I went to the doctor and doctor game be a $300 sort of injection a flu shot so I paid $25 from my pocket as copay and doctor needs to get $275 from me and from the health insurance company because I paid my premium to United Healthcare and I don't have the patient and the dollars here right I don't have to pay because I'm actually paying my premium developer UnitedHealth so that's why I only pay $25 so the doctor she needs to get and 275 dollars so in this case the doctor my doctor is going to spend a 37 P while a 37 PDQ the professional fighter excuse me okay um the doctor is actually sending a HIPAA transaction saying not a I saw I remember Paul and I gave my flu shot he paid me $25 I need to $75 okay so he is going to send an 837 P to the trading process okay then again a one one more thing I want to clarify these trading partners are actually behind the scenes you don't these are technology companies so most of the times the providers the doctors hospitals health insurance done they have a contract with the trading provide a training class they all work behind the scenes so I want to show that process as well because when you're actually working in the health insurance industry we want to know how to straighten parts of it sometimes you have to work with this what a trained economist research so 837 P is a professional became gained just because I went to the doctor and the doctor's office and that's why I am actually using at 8:37 P and it is mandated you have to use a thirty-seven feet for the day if you're actually going to the to a doctor so the doctor is doctors responsibility and the doctor's office responsibility to standard in a 30/70 not 837 I 837 I is used for Hospital transactions only okay so now I got a 30 so the doctor's office sent in a 30/70 professional plane and because they need to get to their 275 dollars they're selling to the trading partners right here okay so 837 P here as you can see now what what happened right here is the doctor's office tended to the trading partners and the trading partners massage the data they process what they call their sleep they are headed there are like five levels of it in other words they're actually massaging the data making sure this file is after this and it meets the mandates and such a once we process it they would actually send this file to the tale system okay now here think um you know these are these are all the lists of health insurance companies every company uses their own system okay now as a part of this course we focus on packets to NXT Madeleine's we actually compare these three tools and basically have a better understanding of how all these three systems work with the difference classes and Q and XT obviously are very popular systems these are a little products okay try little proprietary products here so some in any levels and any information that is being used is basically for correctly to their systems right here as you can see these are all the pages you get that so in this scenario you process the you know identity 3070 into one of these systems say for example United Health is using facet system that I know a company that uses Meadowlands maybe Ethne is using xt so in it being processed in one of the claim has been adjudicated and the next step is basically once it is processed and the system is actually checking hey Paul is our member the system verifies that and Paul went to get a flu shot can you pay 2 fi dollars and he pays $500 s premium okay and we color for his sous-chefs okay we can pay all 235 dollars to dr. it's all good so once it's all good that's when actually it's ending 8:35 here it verifies their electronic remittance advice they will visit with electronic check or basically the wire transfer or something okay so they get it back to the doctor no so in this case we don't actually physically send a check to the doctor's office they they deposit in doctors and thanks a lot boxes and such this will be diagram and I want to show the doctor getting paid but behind the things that it's been deposited electronically into the doctors account okay um okay so there are a couple of things that I want control so as you can see here once it is paid so I went to the doctor three hundred dollars of cost for my flu shots I paid $25 and the doctors down to $35 here is got process and health insurance company said it's all okay and they send you a 35 and doctor got paid once a doctor get paid so this actually process happens simultaneously a member of means has Paul will get ELB a letter saying experience benefits $10 to get a letter of explanation of payment and most health insurance companies give you a login information where you can actually log in and actually go to log into your glendol portal and access you will be in your PC and they also send mails as well so if you check one of your meals from your hospital or a health insurance company right hand side of college with the others this govt explanation of benefits or explanation of payment okay so this is one scenario see where I went to the doctor's office they've got a flu shot and upset okay so in this process I'm going to show you another scenario as well okay I'm going to show you another scenario where a couple and say in this case a couple of you watch for my for our company and the group policy so I provide insurance for us for these couples and they basically both work for our company and we go out insurance for them and so then this group policy they're having a baby so obviously I will a be a passport plan so they need to go to the doctor's office and they need to the doctor reassert to the hospital and this hospital is very forget your baby so this is this example I'm focusing on an inpatient setting where you actually the this lady has Elysee Elysee products or a lot of technologies went to hospital and stayed in the hospital for one week and she had a baby okay that's the scenario all right so she went to the hospital visit it was an inpatient settings she joined her Hospital she wasn't she was admitted to the hospital on Monday and she stayed for one week and she had a baby somewhere on what I say and she got discharged on Friday it lets the scenarios here learn so when he's a couple from our technologies went and had a baby the hospital will actually the again today we go through this process they were verified members of insurance there's a lot of paperwork involved a lot of medication and she had a surgery she met multiple doctors and the baby had a lot of tests ear test i test one or the testers you know maybe wanted a response babies go through a lot of stress you know baby is being taken care and then at the daycare in the hospital as well babajis the hospital recharge adapter and the baby has been taken with why mom is recovering if you clear the baby for who a few hours at night and to all of that these cost okay so my employee and she had a baby and and hospital sent a bill for a thousand dollars okay because she's part of my she and she took a couple of her baby as technology employees and we did for their health insurance and we we paid a premium and then a group insurance is also covered under so we bought some health insurance from the United Health okay as a group we had a group of compliance I want to say 15 employees and we have a group insurance from the United Healthcare and all our insurances are powered selecting so a hospital actually sent in 837 I which is inpatient outpatient so whenever Hospital is standing a claim to health insurance company they always have to send in 837 hi okay so in this case we sent in a 37 I this 837 is very very complicated transactions because she went to a lot that she died at least four or five doctors she had a baby she recovered they gave a lot of medications painkillers did you scare the baby at the daycare and they actually had a lot of sex as well so all of this discussed the hospital may need to get all of that money okay in this case they for example the sustained one of the hospitals charge $20,000 so they said in a 2009 it was a huge transaction again it goes through the same process that goes through the training partners they would actually massage the data and they will spend all of that information into our care system so one of these systems will get that depending on the payer who company which is using these systems David get this 837 I and they will actually process the transaction and the same process occurs again so once the 837 hi then they process it and you actually get the payment so it's all good and she's part of the entire group and for elect technologies because we got everything covered for her and we're going to send in 835 transactions so the difference here you see a 35 is used for both AP and I the reuse the same transaction there is nothing called a at five p or 835 I it's the same translation for the Train format is different and the doctor sends the claim to the health insurance is a very therapy and then hospital since that came to the health insurance companies 837 hi again the process is still the same you're going to get a bill and I show any re explaining the payment explanation of benefits the process this distance so the difference is the bill so here is 235 dollars here's $30,000 okay and hospital called for everything because we have a coverage maternity coverage and such and this is all good ok so ok so there are many many transactions that I have not shared I didn't show in this workflow diagram but these are the most common transactions so there is another transaction we use that's called 276 and 277 it became a status request and response page to the 72 71 that is a eligibility status request response page 278 there is an authorization file that's another transaction so as a part of this course we're going to know each and every transaction in much more detail in the purpose of that transaction we're going to interpret a EDI transaction as well and that's doesn't be powered enabled eat it and also we will be covering the facet the Q and XT systems in much more detail as to how these systems look like how do you look for a claim what are all the basic things that you know we need to know about practice what is a real perk perfect okay so at the end of the day as you can see no matter what system you use the data is still the same there is membership data meaning your BR data and my data my juice for my payment information my address information there is provided there is doctors data because doctors also have contracted the health insurance today's provider data there is payment data so that's the payment data there's benefits data benefits data meaning I pay five hundred and somebody else might pay $800 the screenings because this person has more coverage so there are five different types of health coverage based on your premium fee for different levels as such so depending on your level depending on how much you pay a premium your college is different so that's all benefits information and hope this the slide actually gave you a good overview of how things work