Todays claims facilities are nearly $2.5 trillion or %17.6 of the economy.
CPT codes, ICD-9 and ICD-10 and revenue codes have been mostly standardized by
Claims admin is a core function of any payer. The cost
10% of all medical expenditures!
o 300 billion dollar market
Medicare drug spend 19.8%
Other third parties 62.9% - (cost shifting 20-30%)
Cash spend 8.8%
Evidence of Coverage (EOC) & Pharmacy Bene
Nothing can happen until an individual is enrolled in a payer organization which means
they must first be deemed eligibly for coverage.
The data collected on if patients are eligible for coverage is kept in an
Chapter 30 PPACA
Under the ACA if you are able to afford health insurance you must have it otherwise you
will pay a penalty.
Estimate of cost for the implementation of the ACA have continued to rise each year.
King vs Burwell is a cu
Chapter 2 Types of Health Insurers
Insured Versus Self-Funded Benefits Plans
As of 2010 59% of all group health coverage was through employers self- funded group
health benefits plans, this has been slowly increasing.
Chapter 4 The Provider Network
Reasons for the health plan to contract
Assured that the provider will service plan members
Meeting service access standards required by state and Medicare
Chapter 3 Elements of the Management and Governance Structure
With few exceptions there is no standardization of management governance or
control structure in managed care i.e. the function or presence of a board varies
1910 To The Mid-1940S: The Early Years
Before WWII two distinct models of providing and paying for health care other then outof pocket.
1. The proto-HMOs combined the functions of insurance and the health care
Chapter 5 Provider Payment
Payment of Physicians
Less than 20% of physicians are paid based on a share of practice revenues, the
majority are paid on a Performance-adjusted salary (43.8%).
Physicians are more likely to be an employee
A system of coordinated health care intervention and communications for populations
with conditions in which patient self-care efforts are significant.
Conditions must meet at least 2 criteria: