Healthcare Domain Questions:

1. What is HIPAA?
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was enacted by the
U.S. Congress 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. The Administration Simplification provisions also address the security and privacy of
health data. The standards are meant to improve the efficiency and effectiveness of the nation's
health care system by encouraging the widespread use of electronic data interchange in the
U.S. health care system.

2. General Understanding of Medicare Procedures and Policy.

Medicare is health insurance offered by the Federal government to people who are 65 or older,
people under age 65 with certain disabilities, and people of any age with End Stage Renal
Disease (ESRD) - permanent kidney failure requiring dialysis or a kidney transplant), who meet
the eligibility requirements. Medicare helps pay for health care, but does not cover all medical
expenses. The United States Medicare system is managed by the Centers for Medicare &
Medicaid Services.

● Medicare Part A (Hospital Insurance) is the original Medicare coverage which helps pay
for inpatient hospital care, and helps cover skilled nursing facility, hospice, and home
health care.

● Medicare Part B (Medical Insurance) is for people who qualify for Medicare. It helps
cover doctors' services, outpatient care, and home health care, and helps cover some
preventative services to maintain one’s health and to keep certain illnesses from getting
worse.

● Medicare Part C or Medicare Advantage Plans (like HMOs and PPOs), offer health
coverage options run by private insurance companies approved by and under contract
with Medicare. It includes Part A, Part B, and usually other coverage like prescription
drugs.
● Medicare Part D is the newest addition to Medicare. It is a prescription drug option run
by private insurance companies approved by and under contract with Medicare, that
helps cover the cost of prescription drugs and may help lower one’s prescription drug
costs and help protect against higher costs in the future.

3. Write briefly about Healthcare Processing.

Healthcare claims cover the risk of sickness and offer the benefits given on the event of
hospitalization, surgery, occurrence of illness etc. The benefits which can be claimed under
healthcare products are:
a) Outpatient or General Practitioners care- General Practitioners (GP) cater to the primary care
benefits of the patients and if there is any specialist treatment required then the general
practitioner can refer the patient to a specialist doctor/hospital.
b) Inpatient or Hospitalization including surgery - GP or the Specialist may refer the insured to
an approved hospital. The hospital care includes in-patient treatment and day surgery in the
hospital.
c) Dental will cover the dental benefits like capping, polishing, crowning etc
d) Maternity will cover the benefits including surgery, miscarriage etc.

Depending on the type of health insurance which has been taken, the insured can select the
benefits he wants to be covered for. There are some health care products which cater to special
illness such as cancer, kidney operations. There also some schemes by which the insurance
companies seek to provide benefits to their customers. One such scheme is the Panel
doctors/hospitals concept. A network of General Practitioners, Specialists, clinics etc can be
grouped by the Insurance Company to form a “Panel of Doctors/hospitals”. So, there are a
range of medical products offered by Insurance companies which provide ease of payment for
the insured if he/she visits panel doctor/hospitals. This range of products will be similar to the
standard health care products like except that the hospital payment can be done by cashless
cards and later the hospitals will reimburse the amount from the Insurance Company. There are
also other benefits which are associated with such schemes.

The insured should be well aware of his covered benefits and his insured period (i.e. the time in
which he will be covered, normally the healthcare products are renewable after one year).
Generally the claims procedure in any insurance company for health care products is as follows:

The insured (client who has taken insurance) on the occurrence of an event (such as illness)
can either approach the insurance company directly or the hospital will do it on his behalf in
case of cashless reimbursement. On receiving the bills and the claim form from the
hospital/insured, the claims executive in the insurance company will evaluate the details and
check the eligibility of the claimant (insured) who has made the claim. The Claimant can be the
insured himself or his dependants. The eligibility is needed to be checked in case there is a
claim for benefits for which he may not be applicable for depending on the benefits terms and
conditions. Once the claims executive has verified the eligibility of the claimant the claims will be
processed and the payout amount will be calculated depending on the amount he is eligible for
and the amount he has incurred (billed amount). After the processing, the payout amount will be
forwarded to the Finance/Accounts department for the final payout via the chosen payment
method (can be cheque, draft or bank transfer).

4. What are FACETS?

With an ever evolving and growingly complex health care market, what is required mostly is a
software solution that goes beyond normal processing and helps the organization in responding
quickly and effectively to the changes around the market. The software package should help the
organization in achieving its strategic objectives in the industry while ensuring that there are no
compromises on other fronts. The changes can be driven by several factors such as
government regulations, consumerism, and medical cost trends. FACETS is one of such health
care administration based enterprise-wide software solution. This amazing software platform,
with deeply integrated applications, automates processes across your entire enterprise and
drives greater cost-efficiencies. FACETS also helps in supporting the organization in getting the
consumer-directed products demanded by today's retail health care market and deliver
advanced care management capabilities.
FACETS can help maximize the organization’s operational and business efficiencies through
greater automation and enables seamless transactions between the providers (may be hospitals
or doctors, clinics etc), members and within your plan (which is the actual health care product).
The advanced functionalities which are included with FACETS enable health care plans to
achieve operational efficiency while supporting enterprise-wide business initiatives. “Facets” is a
widely used software solution for health care plan administration and is currently the leading
provider - proven to be the choice for current and emerging business needs in the health care
sector. So, what are the benefits of using FACETS in today’s health care industry? We are
provided with leading-edge functionality to support key business needs, such as consumer retail
products, HAS (Health Savings Account) and FSA (Flexible Savings Account) management,
Medicare/Medicaid, care management and provider network management.
FACETS can reduce the administrative costs to 10% or less through greater auto-adjudication,
integrated workflow management and improved operational efficiencies. It also improves
management of the network by effectively administering complex provider and facility contracts
and accurately forecasting the financial impact of proposed rates and terms. On offer with the
software package is the most choices of leading database option.

5. What is Healthcare Fraud and how do you detect it?

It’s a type of fraudulent and criminal activity related to health care claims in order to make a
profit. Healthcare fraud can be done on the part of the provider (i.e. the hospital or the doctor or
even the medical staff involved) or by the client or patient. Most common type of fraudulent
activity in healthcare activities is providing fake bills in order to get reimbursement either from
employer or directly from the insurance company. Due to the level and dept of penetration there
is a huge loss of revenue-detected world wise. There are plenty of opportunities for fraud to
happen in the healthcare industry but also plenty of methods for detecting it. Contemporary
healthcare is a multilayered and fragmented enterprise composed of competing and conflicting
payers and participants, each with ample circumstances and motives to commit fraud. This
climate presents both tremendous opportunities and significant challenges
for auditors in the healthcare industry. The unfortunate reality of fraud is that once an asset is
stolen, it is gone. The moral is that prevention is key. Barring major changes in the healthcare
delivery system, however, the main thrust of ensuring payment and service integrity will
continue to be on the back end of the process. This is where the auditors come in. Healthcare
fraud is an evolving concept that responds to antifraud pressures by branching out in new
directions or developing additional defenses against detection and new means of concealment.
Auditors should be alert to these emerging issues and attuned to healthcare market trends with
shifts in risks, opportunities, regulations, and business practices. It is important to remember
that, in evaluating evidence, not only must auditors exercise professional skepticism; they must
also be prepared to recognize potential fraud. Information technology can be the answer to
detecting such fraudulent activities in the healthcare industry. There are many software
packages and technology trends, which are up coming and should provide an answer to at least
lessening
such activities, if not completely stopping them. Automated coding software can be studied to
and recommend best practices for the prevention, detection and prosecution of healthcare
fraud. As the healthcare sector embraces electronic health records to reduce medical errors and
improve cost-effective delivery of care, these same technologies have the potential to prevent
and detect healthcare fraud. The major technology approaches from the major players are just
very expensive. The cost of such investments has been very difficult for many companies to get
approved. And most products that are good at spotting such frauds are mostly retrospective.
And it's much harder to get that money back after the check's been sent. It would be beneficial if
the programs could better address fraud prospectively, but then they face trouble from states
with prompt payment laws and HIPAA transaction standards. Clients can have difficulties in
aggressively attacking provider fraud because they need to maintain good relations with their
provider networks. Thus, all we need is the complete cooperation of all parties together with the
right tools to help us curb the healthcare frauds!

6. What are the highlights of the new Healthcare reform?

In March 2010, Congress passed and the President signed into law the ‘Affordable Care Act’,
which puts in place comprehensive health insurance reforms that will hold insurance companies
more accountable, lower health care costs, guarantee more health care choices, and enhance
the quality of health care for all Americans. It began a new era for American consumers in our
health care system. This is the day that a series of new rights, benefits, and protections under
the Affordable Care Act began to bring to an end some of the worst abuses of the insurance
industry. Combined, these new provisions put consumers, not insurance companies, in charge
of their health care.
Whether any individual gets health benefits through work, buys insurance themselves, have a
small business and desire to provide health coverage to their employees, are on Medicare, or
don’t currently have insurance, the Affordable Care Act gives everyone better control of their
own decisions about their health coverage. It makes insurance more affordable right away by
providing small businesses with a tax credit to provide coverage, and in 2014, by providing tax
credits to those who need help in buying insurance- representing the largest middle class tax
cut for health care in history.
The Affordable Care Act is projected to reduce premium costs for millions of families and small
business owners who are priced out of coverage today. This could help as many as 32 million
Americans who have no health care today receive coverage.
Once the Affordable Care Act is fully implemented, Americans will have access to affordable
health coverage.
To help lower costs, the Affordable Care Act:
● Sets up a new competitive private health insurance market - through state Exchanges,
giving millions of Americans and small businesses access to affordable coverage, and
the same choices of insurance that members of Congress will have.
● Holds insurance companies accountable by keeping premiums down and preventing
many types of insurance industry abuses and denials of care, and ending discrimination
 against Americans with pre-existing conditions.
● Puts our budget and economy on a more stable path, since it is expected to reduce the
deficit by more than $100 billion over the next ten years – and by more than $1 trillion
over the second decade – by cutting government overspending and reining in waste,
fraud and abuse.
It was started in 2010 and continuing through 2014, the Affordable Care Act will be
implemented, increasing access to affordable health care for individuals, families, seniors, and
businesses.
Below is a brief summary of the new restrictions for insurance companies and new rights for
consumers beginning to take effect. Insurers No Longer are able to:

● Deny coverage to kids with pre-existing conditions. Health plans cannot limit or deny
benefits or deny coverage for a child younger than age 19 simply because the child has
a pre-existing condition like asthma.

● Put lifetime limits on benefits. Health plans can no longer put a lifetime dollar limit on the
benefits of people with costly conditions like cancer

● Cancel your policy without proving fraud. Health plans can’t retroactively cancel
insurance coverage – often at the time you need it most - solely because you or your
employer made an honest mistake on your insurance application.

● Deny claims without a chance for appeal. In new health plans, you now have the right to
demand that your health plan reconsider a decision to deny payment for a test or
treatment. That also includes an external appeal to an independent reviewer.

Consumers in New Health Plans are able to:

● Receive cost-free preventive services. New health plans must give you access to
recommended preventive services such as screenings, vaccinations and counseling
without any out-of-pocket costs to you.

● Keep young adults on a parent’s plan until age 26. If your health plan covers children,
you can now most likely add or keep your children on your health insurance policy until
they turn 26 years old if they don’t have coverage on the job.

● Choose a primary care doctor, ob/gyn and pediatrician. New health plans must let you
choose the primary care doctor or pediatrician you want from your health plan’s provider
network and let you see an OB-GYN doctor without needing a referral from another
doctor.
● Use the nearest emergency room without penalty. New health plans can’t require you to
get prior approval before seeking emergency room services from a provider or hospital
outside your plan’s network - and they can’t require higher co-payments or co-insurance
for out-of-network emergency room services.