Professional Documents
Culture Documents
Edge Cognitive Computing Besd Healthcare System
Edge Cognitive Computing Besd Healthcare System
If a Company’s business expands and they want to take up additional work without
increasing their Infrastructure or Manpower, the best option is to outsource the non core
functions to another Company at some cost so that they can concentrate effectively on
the core functions and take up more work using the available resources
b. Advantages of Outsourcing to India
Time lag between countries
All expenses (Infrastructure & human resources) are in rupees instead of
dollars.
c. Types of BPO
Voice based (Call Centers)
Non voice based (Transaction processing)
Tela is a Non Voice based BPO specializing in the US Healthcare Insurance Industry.
Hence we need to understand the meaning of Insurance.
2. Health Insurance
Health insurance is protection against medical costs. A health insurance policy is
a contract between an insurer and an individual or group, in which the insurer
agrees to provide specified health insurance at an agreed-upon price (the
premium). Depending on the policy, the health insurance premium may be
payable either in a lump sum or in installments. Health insurance usually
provides either direct payment or reimbursement for expenses associated with
illnesses and injuries.
l. Individual Provider
Refers to an individual person who provides service – nurse, doctor etc
m. Physician - Doctor
o. Subscriber (Policy holder/ The person who subscribes for the policy)
p. Member (Person covered by Insurance Policy)
q. Insured (Person covered by Insurance Policy)
r. Dependent
Some Insurance plans have dependent coverage where the dependents of the
Insured are entitled to benefits under the Plan.
In most cases dependents are either spouse or child <19 years. Children from
19-24 years may be covered in some plans if they are full-time students from an
accredited School/College)
Note:
The Dental form can be submitted before the services are actually rendered in
order to determine the approximate expense: In this case, the form would be a
Request for Pre-authorization.
If the form is submitted after the Services are rendered, it would be a Statement
for actual services.
…………………………………………………………………………………………………..
1. How to identify the different types of HCFA claims on the basis of POS code and
CPT codes:
o HCFA Ambulance claims:
POS is either 41 or 42
41 is for Land Ambulance
42 is for Air/Water Ambulance
Box 32 has a “from and “to” address
Modifiers
HH –Hospital to Hospital
RH- Residence to Hospital
SH – Street to Hospital
HI – Hospital to Institute
o HCFA DME
POS is either 4, 8, or 12
o HCFA Anesthesia
CPT range is 00100 to 01999 or 99100 to 99140
Time units are billed on the claim form
o HCFA Laboratory
POS is 81
Refer to the POS chart and Procedure code chart for more detailed identification and
interpretation of services on a HCFA claim
What do Diagnosis Codes, Procedure Codes, POS codes and Modifiers describe?
A) Diagnosis Codes: It describes the problem or the illness and is 3 to 5 digits in length.
There are three types of diagnosis codes:
1. Medical Code: e.g. 123.45 (All numeric and has a decimal after the first 3 digits)
2. Routine Code: e.g. V12.34 (Starts with “V”)
3. Emergency Code: e.g. E123.4 (Starts with “E” but has a decimal after first 4 digits)
B) POS Codes (Place of Service codes): It describes the place where the service was
provided.
D) Modifiers: It is a two-digit code which when used along with a procedure code provides more
information about the procedure or specifies the procedure.
Place Of Service
Codes Description
3 School
4 Homeless Shelter
11 Office Services
12 Home Health
15 Mobil Unit
21 Inpatient Hospital
22 Outpatient Hospital
25 Birthing Center
32 Nursing Facilities
34 Hospice
41 Land Ambulance
42 Air/Water Ambulance
81 Independent Laboratory
MODIFIERS
Modifier Description
21 Prolonged Evaluation and Management Services
22 Unusual Procedure Services
23 Unusual Anesthesia
Unrelated Evaluation and Management Service by the Same
24 Physician During a Postoperative Period
Significant, Separately Identifiable Evaluation and
Management Service by the Same Physician on the Same
25 Day of the Procedure or Other Service
26 Professional Component
Multiple Outpatient Hospital E/M Encounters on the Same
27 Date
32 Mandated Services
47 Anesthesia by Surgeon
50 Bilateral Procedure
51 Multiple Procedures
52 Reduced Services
53 Discontinued Procedure
54 Surgical Care Only
55 Postoperative Management Only
56 Preoperative Management Only
57 Decision for Surgery
Staged or Related Procedure or Service by the Same
58 Physician During the Postoperative Period
59 Distinct Procedural Service
62 Two Surgeons
66 Surgical Team
Discontinued Out-Patient Hospital/ASC Procedure Prior to
73 the Administration of Anesthesia
Discontinued Out-Patient Hospital/ASC Procedure After
74 Administration of Anesthesia
76 Repeat Procedure by Same Physician
77 Repeat Procedure by Another Physician
Return to the Operating Room for a Related Procedure
78 During the Postoperative Period
Unrelated Procedure or Service by the Same Physician
79 During the Postoperative Period
80 Assistant Surgeon
81 Minimum Assistant Surgeon
Assistant Surgeon (when qualified resident surgeon not
82 available)
90 Reference (outside) Laboratory
91 Repeat Clinical Diagnostic Laboratory Test
99 Multiple Modifiers
Anesthesia services performed personally by
AA anesthesiologist
Medically supervised by a physician for more than four
AD concurrent procedures
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
Confidential 11 of 39 Property of Tela Sourcing India (Pvt) Ltd.
BASIC ADJUDICATION TRAINING
1 MD Doctor of Medicine
2 DO Doctor of Osteopathy
3 MS Master of Science / Master of Surgery
4 DC Doctor of Chiropractics
5 DPM Doctor of Podiatric Medicine
6 OD Doctor of Optometric
7 DDM Doctor of Dental Medicine
8 DMD Doctor of Medical Dentistry
9 DDS Doctor of Dental Surgery
10 RN Registered Nurse
11 LVN Licensed Vocational Nurse
12 LPN Licensed Practical Nurse
13 CNA Certified Nurse Assistant
14 CNM Certified Nurse Midwife
15 CNP Certified Nurse Practitioner
16 CRNA Certified Registered Nurse Anesthetist
17 RPT Registered Physical Therapist
18 LPT Licensed Physical Therapist
19 MFC Marriage Family Counselor
20 MSW Master of Social Work
21 MT Medical Technologist
22 PhD Doctor of Philosophy
23 MPH Master of Public Health
24 MRL Medical Record Librarian
25 BM Bachelor of Medicine and surgery
26 PT Physical Therapist
27 OT Occupational Therapist
28 PT Speech Therapist
29 CCSW Certified Clinical Social Worker
30 FNP Family Nurse Practitioner
ABBREVIATIONS
1. Degrees
2. Other Abbreviations:
MEDICAL TERMINOLOGIES
37. CAT Scan (Computed Tomography Scan) is a diagnostic test that selects a level in the body
and blurs out structures above and below it leaving a clear image of the selected anatomy.
38. Bone Scan is a diagnostic test that is used to visualize bones.
39. PET Scan (Positron Emission Tomography) is a diagnostic exam that involves physiologic
images based on the detection of radiation from the emission of positrons. Positrons are tiny
particles emitted from a radioactive substance administered to the patient.
40. Occupational Therapy is a treatment using constructive activities to improve functional
restoration of a person’s lost or impaired ability to be able to do ordinary tasks for daily living.
41. Speech Therapy is the correction of speech impairment to the level before impairment,
disease, or injury.
42. Temporomandibular Joint Syndrome (TMJ) : Severe aching pain in and about the
temporomandibular joint (where upper & lower jawbone join) made worse by chewing.
43. Transplant is the grafting of living tissue from its normal position to another site or the
transplantation of an organ or tissue from one person to another.
PLAN TYPES
Government Plans
1. Medicare
a. Federal health insurance program.
b. People Eligible are
i. People aged 65 or older
ii. People less than 65 years with disabilities
iii. People with End-Stage Renal Disease (ESRD), which is permanent
kidney failure requiring dialysis or a kidney transplant.
c. Medicare has two parts:
Part A, - hospital insurance,
Part B - supplementary medical insurance, which provides payments for doctors
and related services and supplies ordered by the doctor.
Part A is free, but you must pay a premium for Part B.
2. Medicaid
a. Medicaid is a joint federal-state health insurance program that is run by the
states.
b. Low-income people – People below the FPL (Federal Poverty Line) (especially
children and pregnant women), and disabled people.
………………………………………………………………………………………………………………
Commercial Plans
1. Indemnity Plans
With an indemnity plan (sometimes called fee-for-service), you can use any
medical provider (such as a doctor and hospital). You or they send the bill to the
insurance company, which pays part of it. Usually, you have a deductible—such
as $200—to pay each year before the insurer starts paying.
Once you meet the deductible, most indemnity plans pay a percentage of what
they consider the "Usual and Customary" charge for covered services. The
insurer generally pays 80 percent of the Usual and Customary costs and you pay
the other 20 percent, which is known as coinsurance. If the provider charges
more than the Usual and Customary rates, you will have to pay both the
coinsurance and the difference.
The plan will pay for charges for medical tests and prescriptions as well as from
doctors and hospitals. It may not pay for some preventive care, like checkups.
2. Managed Care
a. HMO
i. Staff Model
ii. Group Model
iii. Network Model
iv. IPA
b. PPO
c. POS
d. EPO
o Deductibles
An amount the covered person must pay before payments for covered services begin.
For example, a $500 deductible means that an individual must pay for the first $500 worth of
health care expenses before the insurance company begins to pay for services for the rest of the
year.
a. Individual Deductible
b. Family Deductible
o Co- insurance
Co-Insurance refers to money that an individual is required to pay for services, after a deductible
has been paid.” Co-insurance” is often specified by a percentage. For example, the employee
pays 20 percent towards the charges for a service and the employer or insurance company pays
80 percent. It is a cost-sharing arrangement between an insured person and the health insurance
company in which the insured person is required to pay a percentage of the cost for health care
services received. Coinsurance typically applies after satisfaction of a deductible. For example,
80% coinsurance may apply after a $500 deductible has been satisfied. For Medicare Physicians’
Services. The beneficiary pays co-insurance of 20 percent of allowed charges.
1. Group Insurance
In-group Health Insurance, a single policy covers the medical expenses of many different people,
instead of covering just one person. Unlike individual insurance, where each person’s risk
potential is evaluated to determine insurability, all eligible people can be covered by a group
policy, regardless of age or physical condition. The premium for group insurance is calculated
based on the characteristics of the group as a whole, such as average age and degree of
occupational hazard.
Many employers offer group health insurance as part of their employee benefits package. Other
groups that may offer insurance coverage include churches, clubs, trade associations, chambers
of commerce, and special-interest groups.
Affordable
In many cases the employer or association will pick up some or the entire group insurance
premium. This can make group insurance even more affordable.
2. Individual Insurance
Individual insurance covers the medical expenses of only one person or family. Unlike group
insurance, the individual purchases the individual insurance directly from an insurance company.
When any person applies for individual insurance, they are evaluated in terms of how much risk
they present. This is generally done through a series of medical questions and /or a physical
exam. Their risk potential determines whether they qualify, and how much their insurance will
cost.
Before issuing an individual insurance policy, the insurer obtains the individual’s personal health
history. If the insurer doesn’t want to cover a particular health condition, any person may still be
able to get a policy with an exclusion rider.
If available, group insurance is generally a better option, since it is usually more comprehensive
and less expensive than individual insurance. However, individual coverage is infinitely better
than being uninsured in the event of illness or Injury. Although one may think that one can do
without health insurance, there exists a major risk for choosing not to get coverage. An
unexpected illness or serious injury can put an individual or their close family in financial peril.
In a group insurance situation, the provisions of the policy are negotiated between the insurer and
master policy owner (usually an employer or association). With individual insurance, an individual
is directly in control of the insurance policy. An individual can negotiate to have certain provisions
included or excluded, and can often chose their deductible amount and co-payment percentage.
However, the insurance premiums will depend on the deductible and Co-pays.
GLOSSARY
Other Terminology.
1. Self funded /Self Insured Plan:
Basic Definition
Usually in large Companies, the Employer may prefer to invest in a fund
(managed by the Employer himself) to support Insurance for its employees rather
than paying premium to Insurance Company. In this case whenever a claim in
incurred, money is withdrawn from this fund. However, the responsibility of
creating the Policy and also the work of processing claims may be outsourced to
a TPA. The benefit if this kind of plan is that the funds left over after all claims are
paid will belong to the Employer instead of the Insurance Company.
Other definitions
Employers may elect to self-insure or self-fund an employee benefit program
rather than obtain coverage through an insurance company. This funding method
offers employers an option to standard insurance contracts.
Self-insured plans are employee benefit plans or programs which are funded
through financial vehicles other than insurance contracts. Self-insured plans may
also be called self-funded programs. They can be funded through employer
contributions, employee contributions, or a combination of both.
Some self-insured plans are funded through the unsegregated general assets of
a company. These plans are often called "pay as you go" programs. Other plans
are funded by making contributions to a segregated trust fund which accumulates
contributions (employer and/or employee) specifically for the purpose of funding
a benefit program.
Self-funded/self-insured plans may include short term disability, long term
disability, medical benefits, etc. Almost any type of benefit plan provided through
an insurance policy can also be delivered on a self-insured/self-funded basis.
Self-funded vehicles were established to provide benefit funding options to
employer groups or other group purchasers/users of benefit programs.
The costs associated with a self-insured program are the following:
• the actual costs of the benefits paid,
• costs for claim administration, including enrollment and termination processing,
and
• cost associated with the collection of plan contributions.
An employer undertakes a detailed financial planning process to decide whether
it would be optimal to self-fund or insure.
4. Actuary
An expert who calculates insurance risks and premiums. It is the actuary's
responsibility to see that an insurer's operations are conducted on a sound
financial basis through setting adequate premium rates and policy reserves.
5. Underwriter
Underwrite - literally, to set one's name to an insurance policy and thereby
become responsible for a designated loss. An underwriting department in an
insurance company is responsible for evaluating and accepting or rejecting
applications for coverage. An individual who performs these tasks for an insurer
is termed an underwriter.
7. TPA
An organization that handles the administrative duties of claims administration.
TPA’s are typically used by organizations that self-fund health benefits but do not
find it effective to administer the plan themselves.
Basic Definition:
Most Self funded Plans as well as Insurance Companies prefer to have a backup
plan in case the claims incurred for that year exceed the fund set aside for the
claims. In order to do so, they purchase re-insurance. The re-insurance Company
is responsible to cover all losses above the maximum set aside.
Other definitions:
A term used to describe policies, which are designed to spread a risk between
two or more insurers. Reinsurance may be purchased by employers to reimburse
large claims incurred under self-funded employee benefit plans.
9. Preferred Provider
A preferred provider is a health care provider who has made an agreement with
your plan to offer health care services at a discounted price. A Preferred Provider
is also referred to as Participating Provider, Par Provider, In-Network
Provider.
11. Authorization
Authorization can be defined as the permission that a member is
required to obtain before he can avail certain services.
In HMO plans, the member needs authorization from the PCP to
receive service from any other Provider in the Network
Other plans require authorization for admission to a hospital
Authorization may also be required for services like Surgery etc.
12. Referrals
If a PCP determines a member requires services that he/she cannot render, the doctor refers
the member to a provider who can provide those services. The PCP completes a referral and
lists the services to be provided by the specialist. The referral should identify the patient, the
authorized services, the number of visits authorized, the name of the specialist provider, and
the dated signature of the PCP. The PCP must use the Maryland Uniform Consultations
Referral Form when referring patients. The referral form can be mailed or faxed. Some plans
do not require a paper referral and will accept a phone call from the primary care physician’s
office.
o Referrals may be good for one or more visit(s). For example, a referral to a
cardiologist for evaluation of hypertension may be good for only one visit, but a
referral to an orthopedic surgeon for treatment of a fracture may be good for multiple
visits.
o It is also important to check the date when the member’s PCP completed the referral.
This is necessary to confirm the referrals’ validity at the time of the appointment. If
too much time has elapsed between the date the referral was completed and the
specialist visit, the member will need to obtain another referral from his/her PCP.
o A referral may be valid for as long as 90 days, but a member may lose his/her benefit
eligibility through loss of employment (or any other reason). Before services are
rendered, the member’s eligibility must be verified by the doctor’s office.
o As indicated on the referral completed by the member’s PCP, the specialist may
provide certain services to the member, but he/she is not responsible for coordinating
the member’s care. If additional services are necessary for diagnosis and treatment,
the specialist should report his findings to the PCP and await approval for further
treatment.
o Referrals made to other specialists without the proper referral from the patient’s PCP
may result in either nonpayment or payment at a reduced rate leaving much of the
responsibility to the member (dependant on the type of health insurance plan).
Adhering to this method of coordinating care allows the PCP to control the member’s
utilization and quality of care.
Utilization review is a method used to determine the medical necessity and quality of
services rendered. The review may take the form of either a pre-admission review (called
pre-certification), a concurrent review, or retrospective review. It is not unusual for
managed care organizations to engage in all three types of utilization review.
24. UR & C (Usual, Reasonable & Customary) or R & C (Reasonable & Customary)
a. Usual, reasonable, customary and regular terminology is used to signify the
extent of benefits, which are available under any particular plan provision. Rather
than indicating a scheduled amount for each possible benefit, a plan may provide
for payment of covered charges to the extent such charges are reasonable for
the areas where a service is provided and for the type of service provided.
b. R&C rates are applicable to Non Par Providers. If a member avails service out of
network, the MCO will only reimburse only at R&C rates. Any charge billed by the
Provider that exceeds the R & C rates becomes the responsibility of the Member.
Example:
R & C for Injection = $ 100
Non Par Provider bills $150
MCO will consider only R & C i.e. $100 for reimbursement.
The difference between R&C and billed ($150 – $100 = $50) is considered as non
covered and will be the Patient’s responsibility.
30. Eligibility
Common Criteria to become eligible for a plan
a. Should be an employee
b. Should be a dependent if plan has dependent coverage(either spouse or
child <19 years) Children from 19-24 years may be covered in some
plans if they are full-time students from an accredited School/College)
c. Should be “Actively at Work” when the plan becomes effective.
33. Subrogation
In simple words:
If an Insured incurs a loss due to another party (common example is accident),
the Insurance Company will have to reimburse the Insured for losses incurred,
but can then sue the Third party in order to recover the amount.
Similarly if the Insured causes loss to a third party, the Insurance Company will
have to reimburse the third party although it may be the fault of the Insured
(incase the Insured was drunk while driving). However, it can then sue the
Insured and recover the losses.
36. COBRA
What happens if you or your family member leaves the job? You will lose
your employer- supported group coverage. It may be possible to keep
the same policy, but you will have to pay for it yourself. This will certainly
cost you more than group coverage for the same, or less, protection.
A Federal law makes it possible for most people to continue their group
health coverage for a period of time. Called COBRA (for the
Consolidated Omnibus Budget Reconciliation Act of 1985), the law
requires that if you work for a business of 20 or more employees and
leave your job or are laid off, you can continue to get health coverage for
at least 18 months. You will be charged a higher premium than when you
were working.
You also will be able to get insurance under COBRA if your spouse was
covered but now you are widowed or divorced. If you were covered
under your parents' group plan while you were in school, you also can
continue in the plan for up to 18 months under COBRA until you find a
job that offers you your own health insurance.
Other Explanation:
COBRA contains provisions giving certain former employees, retirees,
spouses former spouses, and dependent children the right to temporary
continuation of health coverage at group rates. This coverage, however,
is only available when coverage is lost due to certain specific events.
Group health coverage for COBRA participants is usually more
expensive than health coverage for active employees, since usually the
employer pays a part of the premium for active employees while COBRA
participants generally pay the entire premium themselves. It is ordinarily
less expensive, though, than individual health coverage.
The qualifying event requirement is satisfied if the event is :
(1) the death of a covered employee;
(2) the termination (other than by reason of the employee's gross
misconduct), or a reduction of hours, of a covered employee's
employment;
(3) the divorce or legal separation of a covered employee from the
employee's spouse; (
4) a covered employee becoming entitled to Medicare benefits under
Title XVIII of the Social Security Act; or
(5) a dependent child ceasing to be a dependent child of the covered
employee under the generally applicable requirements of the plan and a
loss of coverage occurs.
not require any employer to establish a pension plan. It only requires that
those who establish plans must meet certain minimum standards. The
law generally does not specify how much money a participant must be
paid as a benefit. EBSA's compliance assistance information will assist
employers and employee benefit plan officials in understanding and
complying with the requirements of ERISA as it applies to the
administration of employee pension and welfare benefit plans.
38. Global Package: Global package is a one-time cost for an entire treatment. The
reimbursement made by the Insurance Company would cover the main procedure as well as
other related procedures. The most common example would be a global package for pregnancy.
If pregnancy is covered under a global package, the Insurance Company would have to pay a
lump sum amount for the entire pregnancy. This payment would cover all the expenses related to
the pregnancy including all office visits during the pregnancy but excluding the first visit where the
pregnancy was first detected.
The following components constitute a common global surgical package when performed
by the same physician:
Preoperative Visits: Preoperative visits after the decision is made to operate beginning
with the day before the day of surgery for major procedures and the day of surgery for
minor procedures.
Intraoperative Services: Intraoperative services that are normally a usual and necessary
part of a surgical procedure.
Complications Following Surgery: All routine additional medical or surgical services
required of the surgeon during the postoperative period of the surgery including
complications which do not require additional trips to the operating room; also includes
writing orders, talking with the family, evaluating the patient in the post-anesthesia
recovery area.
………………………………………………………………………………………………….………