About US Healthcare For Beginners

US HEALTHCARE

Whether you are planning to start your career in US Healthcare industry, already working in US Healthcare industry and want to get a refresher training or just curious to know what US Healthcare industry is all about, you have arrived at the right page. This article is intended to help everyone and anyone willing to know basics of US Healthcare industry.

In a layman's term, US Healthcare industry is divided into two categories (in terms of business): Provider's (Doctors) end and Insurance's end. Provider's end business is commonly referred to as RCM- Revenue Cycle Management, Medical Billing, Practice Management and so on whereas insurance's end business is referred to as Claim adjudication undertaken by various insurance companies. business subsidiaries, MSOs (Management Services Organization) etc. and these MSOs further outsource their business to various claims adjudicating (processing) companies.

Let's learn something about them below:

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What is RCM?

RCM stands for Revenue Cycle Management. It refers to the process of managing the financial aspects of healthcare services, from patient registration and eligibility verification to claims processing and payment collection. The goal of RCM is to optimize the revenue cycle and improve financial performance for healthcare organizations.

RCM includes various activities, such as coding and billing, claims management, denial management, and payment posting. It also involves ensuring compliance with healthcare regulations, such as HIPAA (Health Insurance Portability and Accountability Act) and CMS (Centers for Medicare and Medicaid Services) guidelines.

Effective RCM can help healthcare organizations streamline their revenue cycle, reduce denials and rejections, accelerate payment collections, and improve overall financial performance. It requires a combination of technology, processes, and skilled personnel to manage and optimize the revenue cycle. RCM cycle ends when a claim closed (paid or adjusted off) in PMS (Practice Management Software).

Types of US Medical/Health Insurances:

A. Federal/State Insurance

✔Medicare

This is a federal health insurance program for people who are 65 years of age or older, younger people with disabilities, and people with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS). Medicare is administered by the Centers for Medicare & Medicaid Services (CMS), a federal agency within the U.S. Department of Health and Human Services.

Medicare is funded through payroll taxes, premiums paid by beneficiaries, and general revenue. There are four parts to Medicare:

1. Part A (Hospital Insurance): This covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.

2. Part B (Medical Insurance): This covers doctor's services, outpatient care, preventive services, and medical equipment.

3. Part C (Medicare Advantage): This allows beneficiaries to receive their Medicare benefits through a private health insurance plan.

4. Part D (Prescription Drug Coverage): This covers prescription drugs and is offered through private insurance companies.

✔Medicaid

This is a joint federal and state program that provides health insurance to low-income individuals and families, pregnant women, children, and people with disabilities.

✔CHAMPUS/Tricare (Civilian Health and Medical Program of the Uniformed Services)

This is a health care program for military members, retirees, and their families who are not eligible for military health care.

✔ChampVA (Civilian Health And Medical Program Of The Department Of Veterans Affairs)

This is a health care program for veterans who have served in the U.S. military.

B. Commercial/Private Insurance

Commercial insurance is a type of health insurance that is purchased by individuals or provided by employers through a private insurance company. Here are some of the main types of commercial insurance in the US:

- Preferred Provider Organization (PPO): PPO plans provide a network of healthcare providers that members can choose from. Members usually pay lower out-of-pocket costs if they see providers within the network, but can see providers outside the network as well.

- Health Maintenance Organization (HMO): HMO plans also provide a network of healthcare providers, but members are typically required to choose a primary care physician and must receive referrals to see specialists. - Exclusive Provider Organization (EPO): EPO plans are similar to PPO plans, but members are usually only covered for services received within the network. - Point of Service (POS): POS plans combine features of both HMO and PPO plans. Members can choose to see providers within or outside the network but may need a referral to see a specialist. - High Deductible Health Plan (HDHP): HDHP plans have higher deductibles and out-of-pocket costs than traditional insurance plans, but usually have lower monthly premiums. They are often paired with a Health Savings Account (HSA), which allows members to save pre-tax money to pay for healthcare expenses. - Indemnity Plan: Indemnity plans offer the most flexibility in terms of choosing healthcare providers but may require members to pay for services upfront and submit claims for reimbursement. - Consumer-Driven Health Plan (CDHP): CDHPs are similar to HDHPs, but also include tools and resources to help members make informed decisions about their healthcare spending. They often include features like price transparency and cost comparison tools.

C. Liability Insurance

✔Worker's Compensation Insurance

Worker's Compensation Insurance is a type of insurance that provides benefits to employees who are injured or become ill as a result of their job. This insurance is typically required by state law, and provides coverage for medical expenses, lost wages, rehabilitation costs, and death benefits in the case of a work-related death.

Workers' compensation insurance is designed to protect both employees and employers. Employees are protected by receiving compensation for their work-related injuries or illnesses, and employers are protected from lawsuits related to these injuries or illnesses. In exchange for this protection, employees give up their right to sue their employer for damages related to the injury or illness.

The cost of workers' compensation insurance is typically paid for by the employer. Premiums are based on a variety of factors, including the size of the company, the industry it operates in, and the number of claims that have been made in the past. Employers are required to carry workers' compensation insurance in order to comply with state law and protect their employees.

Workers' compensation laws and regulations vary by state, so it's important for employers to understand the requirements in their state and ensure that they are complying with them.

✔No Fault Insurance

No-fault insurance is a type of automobile insurance policy that pays for medical expenses, lost wages, and other related expenses resulting from a car accident, regardless of who was at fault for the accident. This type of insurance is designed to provide quick and efficient coverage for accident victims, without the need for lengthy and costly legal battles to determine fault.

In a no-fault insurance system, each driver's insurance company pays for the damages and expenses incurred by their own policyholder, up to the policy limit. This means that even if one driver is found to be at fault for the accident, the other driver's insurance company will still pay for their damages and expenses.

The purpose of no-fault insurance is to streamline the claims process and reduce the amount of time and money spent on legal proceedings to determine fault. However, this system also limits an injured person's ability to sue the other driver for damages, unless the injuries are severe enough to meet certain thresholds.

No-fault insurance is not available in all states in the US, and the requirements and regulations can vary between states that do offer it. It's important for drivers to understand the insurance laws in their state and make sure they have the appropriate coverage to protect themselves and others in the event of an accident.

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