Overview of Healthcare Domain

Role of Business Analyst

Business analysts play a vital role in the healthcare domain by focusing on claims processing and workflow.

Subscriber: Individual who meets eligibility requirements for a health plan and accepts financial responsibility for premiums, co-payments, coinsurance, and deductibles.
Member: Person eligible to receive benefits from a health plan, including dependents.
Provider: Supplier of healthcare services (e.g., hospitals, labs, physicians).
Claim: Detailed invoice sent by the provider to the insurance company for services rendered, including member ID and demographics.
Coinsurance: Cost-sharing model where the member pays a percentage of the service cost, typically after a deductible.
Out-of-Pocket Maximum: Maximum amount a member pays in a year; costs beyond this are covered by insurance.
Co-payment: A fixed fee paid by the member per service (e.g., $30 for a doctor's visit).
Deductible: The amount paid by the member before insurance coverage begins (e.g., $500 per year).

EDI (Electronic Data Interchange): Computer-to-computer exchange of business documents in a standard electronic format.
PHI (Protected Health Information): Confidential demographic and medical information that must be securely transmitted.
HIPAA (Health Insurance Portability and Accountability Act): Law setting standards for the privacy and security of health information.
- Title I: Protects insurance coverage during job loss or change.
- Title II: Establishes national standards for processing healthcare transactions.
Coordination of Benefits: Process for individuals with multiple health plans to ensure coverage does not exceed 100% of charges.
ICD Codes (International Classification of Diseases): Coding system for classifying diseases; ICD-10 has 68,000 codes compared to 13,000 in ICD-9.
HL7: Framework for the exchange and retrieval of electronic health information.
X12: Standards for EDI files related to healthcare transactions.

Member Visits Provider: The member seeks services from an in-network healthcare provider.
Claim Submission: The provider submits an encrypted claim to the insurance company with details about the patient and services received.
Claim Processing: The insurance provider verifies claim data and processes the payment.
Explanation of Benefits (EOB): Sent to the member detailing services received and payments made.
Billing: If applicable, the provider sends a bill to the member for any remaining balance.

Commercial Plans:
- PPO (Preferred Provider Organization): Flexible provider options with coverage for out-of-network services.
- EPO (Exclusive Provider Organization): Requires use of a predetermined network for services.
- HMO (Health Maintenance Organization): Access to specific providers within a network, with lower costs for in-network services.
- Supplemental Insurance: Covers gaps in primary insurance.
- Medigap: Coverage for healthcare costs not covered by Medicare.

HIPAA Transactions: Standardized files for transferring healthcare information.
- 270: Request for coverage information.
- 271: Response providing coverage information.
- 834: Benefit enrollment document for insurance providers.
- 835: Payment details for healthcare providers.
- 837: Standard healthcare claims file.
- 276: Status inquiry for previous claims.
- 277: Response on claim status.

Enacted in March 2010, aimed at increasing coverage accessibility and lowering costs for patients while prohibiting exclusion based on pre-existing conditions.

Verification of patient eligibility for services before appointments, including co-pays, deductibles, and out-of-pocket maximums.
Pre-authorization: Ensures that patients meet specific criteria before receiving services.

The healthcare domain involves various processes, terminologies, and regulatory standards crucial for understanding claims processing and the role of business analysts.