Healthcare BA

Healthcare BA

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    BA Healthcare Course Content:

    1.Healthcare Market Overview

    • Introduction
    • Current healthcare market trend in US
    • What is an HMO
    • The Industry Outlook
    • Trends in Healthcare – Provider Space
    • Trends in Healthcare – Payer Space
    • Key Players
    • References

    2.Healthcare Overview

    • Unit Objectives
    • Genesis Of Healthcare
    • How the industry Works?
    • Healthcare pillars
    • Members
    • Providers
    • Benefits
    • Claims
    • Sales
    • External Agents
    • Healthcare workflow
    • Summary
    • Review Questions
    • References

    3.Members

    • Unit Objective
    • Introduction
    • Insurance Business: An Overview
    • Individual and Group Insurance in detail
    • Individual Insurance
    • How to get individual insurance?
    • Group Insurance
    • Company Paid Groups
    • Affinity Groups
    • Self Insured Group
    • Self-Employed Members
    • Exercise

    4.Member’s enrollment

    • What is Enrollment?
    • How is enrollment carried out?
    • Output of enrollment process
    • Enrollment: Overall Picture
    • Exercise

    5.Member’s and Dependent’s eligibility

    • Eligibility
    • Eligibility Process
    • How a member should approach right provider?
    • Eligibility Data Transfer
    • Eligible Dependents
    • Exercise

    6.Member Services

    • Means of services
    • Services provided by the insurer
    • Premium Collection
    • Member Group Maintenance
    • What are Groups?
    • Groups Formation
    • Groups Maintenance
    • Disability Benefits
    • Member’s concern
    • Exercise

    7.Provider

    • Provider types
    • Provider Participation
    • Provider Contract
    • Provider Contract Process
    • Credentialing Criteria
    • Verification of Provider Credentialing Information
    • Types of Contracts
    • Provider Reimbursement
    • Exercise
    • Provider Referral
    • Referrals processing
    • Referral types
    • Provider Network
    • Quality Provider Networks
    • Network Adequacy
    • Rental networks
    • Network Hospital Standards
    • Provider maintenance
    • some common information of Providers
    • Exercise
    • Review Questions
    • References

    8.Sales

    • Unit Objectives
    • Introduction
    • Brokers
    • Calculation for Brokers
    • Quote Creation
    • What is a quote?
    • The Process Of Quote Creation
    • Actuaries
    • Underwriters
    • Insurance Payer’s Sales Department
    • External Agents that deal with Sales Department of Insurance Payers
    • Review Questions

    9.Benefits

    • Unit Objectives
    • Introduction
    • Indemnity Plans
    • Managed Care Plans
    • Health Maintenance Organization (HMO)
    • Preferred Provider Organization (PPO)
    • Point Of Service (POS)
    • Exclusive Provider Organization (EPO)
    • Which plan is the best?
    • Exercise
    • Other Plans
    • Vision Plans
    • Dental Plans
    • Pharmacy Plans
    • Medicare Plans
    • Medigap
    • Medicaid
    • Long Term Care
    • Disability Income Insurance
    • Catastrophic Coverage Plans
    • Exercise
    • Individual Insurance and Group Insurance
    • Laws and Legislations
    • Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA)
    • Health Insurance Portability and Accountability Act (HIPAA)
    • Review Questions
    • References

    10.Claims

    • Claim generation and submission to Providers
    • Claims Intake Process
    • Claims Intake : Diagrammatic
    • Claim Adjudication Process
    • Claim Preparation and determining eligibility
    • Determine payment
    • Update Claim
    • Claim adjudication outputs
    • Claim Payments
    • Provider Payments
    • Member Re-imbursement
    • Member Re-imbursement
    • Refund Adjustment
    • Minus Debit Adjustment
    • Minus Debit Adjustment
    • Minus Debit Adjustment
    • Stop Adjustment
    • Government reporting
    • Explanation of Benefits (EOB)
    • Accumulators
    • What are Accumulators?
    • Function/Purpose of Accumulators
    • What is accumulated?
    • Types of Accumulator
    • Overall Claims system diagram
    • Review Questions
    • References

    11.External Agents

    • Unit Objectives
    • Introduction
    • Government Agencies
    • Centers for Medicare & Medicaid Services (CMS)
    • Department Of Health And Human Services (DHSS)
    • Centers for Disease Control and Prevention (CDC)
    • Agency for Health Care Research and Quality (AHRQ)
    • National Information Center on Health Services Research and Health Care Technology (NICHSR)
    • Health Resources and Services Administration (HRSA)
    • Exercise
    • Government Acts and Regulations
    • HIPAA
    • Electronic Health Transaction Standards
    • CORBA
    • Exercise
    • Clearing Houses
    • Benefits Of A Clearinghouse
    • Clearinghouse versus Direct Filing
    • Clearinghouse Income
    • Exercise
    • Third Party Administrators
    • Specialized Adjudication Engines/Companies
    • General Agents
    • Accreditation Agencies
    • The Accreditation Process
    • Drug Manufacturers
    • Review Questions
    • References

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