US Healthcare System.

The US healthcare industry is one of the largest industries in the world and is a bit complex compared to other countries. It is a mixed system where publicly and privately financed market coverage coexists with each other.

A patient is any recipient of health care services performed by healthcare professionals. The patient is most often ill or injured and in need of treatment

‘Providers’ are individuals or institutes who provide healthcare treatment to patients. Providers are usually doctors, but they can also be nurses, surgeons, x-ray technicians, physical therapists, etc.

Payers (Payor) are the health insurance companies responsible for paying for the patient’s medical services. Payers are responsible for setting service rates, collecting payments, processing claims and paying providers claims.

Healthcare payment models are billing systems by which healthcare organizations get paid for the services they provide to patients, whether by insurance payers or patients themselves.

Medical coding is the translation of medical reports into a short code used within the healthcare industry. This helps summarize otherwise cumbersome medical reports into efficient, data-friendly codes.

A clearinghouse is the liaison between healthcare providers and insurance payers for managing end-to-end healthcare payment processes. A healthcare provider can submit a medical claim directly to the insurance payers or via a clearinghouse

Medical Claims are basically bills (i.e charges for medical care) that a healthcare provider submits to a patient’s insurance company (payer) for the reimbursement after the patient receives medical care.

The most common data formats when it comes to healthcare data and its exchange are Electronic Data Interchange, Health Level 7 and Fast Health Interoperability Resources (FHIR)