US Healthcare System.

This program aims to give a high-level overview of the US healthcare system. It describes the key entities in US healthcare and how they interact with each other. It introduces and describes key entities: Patient, Providers, Payers, and Clearinghouse. It also explains the key terms that are used in revenue cycle management to give you the complete picture of what happens after the patient gets service from a healthcare provider and how healthcare providers get paid.

This program will make you understand about medical codes, clearing houses, medical claims, different payment models and common data formats that are used in the US healthcare system.

Healthcare modules

Introduction to US healthcare

Introduction to US healthcare

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.

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Patient

Patient

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

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Introduction to Providers

Introduction to Providers

‘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.

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Payers

Payers

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.

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Healthcare Payment Model

Healthcare Payment Model

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.

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Medical Codes

Medical Codes

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.

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Clearing House

Clearing House

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

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Medical Claims

Medical Claims

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.

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Common Data Formats

Common Data Formats

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)

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