April 30, 2024

US Healthcare System and Medical Billing

Signetic Tech Talk Tuesdays Session 3 : US Healthcare System and Medical Billing

Pratik Gauchan, Manager of Pharmacy Operations at Signetic, delivered an insightful and detailed Tech Talk on May 28, 2024 on the intricacies of the US healthcare system and medical billing. He shared valuable knowledge and perspectives shaped by extensive experience in medical billing since 2015.

Understanding the US Healthcare System

The presentation began with a comprehensive overview of the US healthcare system, highlighting its complex nature. The system consists of payers, members and various healthcare providers, including hospitals, clinics, private practices, primary care physicians, specialists, urgent care centers, and long-term care facilities. Regulatory bodies such as the CMS, HHS, FDA, and CDC also play a critical role in this ecosystem.

Health Insurance is set up in two ways. First, there’s private insurance which is funded by premiums paid by individuals or employers and administered by private companies such as Aetna, United Healthcare, Cigna, BCBS. Then, there’s public insurance, which is funded by tax revenues and administered by government agencies such as Medicare, Medicaid, CHIP, Tricare.

Image 1: Comparison of private and public health insurance coverage

The presentation highlighted the significant healthcare expenditure in the US, amounting to $4.5 trillion, which is 17.3% of the GDP. This represents a per capita spending of $13,493, a figure substantially higher than in other developed nations. The driving factors behind these costs include an aging population, rising prices for medical services, increased prevalence of chronic diseases, and high administrative expenses. The Affordable Care Act (ACA) was noted for its role in establishing Health Insurance Marketplaces, reducing the uninsured population to 26 million out of 330 million.

Image 2: Healthcare costs per country

Medical Coding and Billing

Medical coding and billing is the process of submitting and following up on claims to ensure reimbursement for healthcare services. The presentation provided a detailed look at the process, starting from patient registration to the final payment.

Common terminologies:

  • ICD-10 (10th Revision of the International Classification of Diseases)
  • CPT (Current Procedural Terminology)
  • NDC (National Drug Code)
  • EOB (Explanation of Benefits) / ERA (Electronic Remittance Advice)
Image 3: Medical Claim Process

The Signetic Billing System

Pratik explained how the Signetic Billing System automates various aspects of the billing process, reducing manual errors and increasing efficiency. It also aids in appointment scheduling for both patients and staff and encourages patient engagement through personalized outreach via automated email and SMS campaigns.

Signetic’s Billing System consists of:

  • Patient App
  • Staff App
  • Manager Portal
  • Billing Operations Portal (BOP)
  • Integrated Claims Editor (ICE)
  • Dashboard
Image 4: Signetic Billing System

These tools work together to enhance patient interaction, assist staff in managing billing and patient information, provide managers with a comprehensive view of operations, centralize billing activities, facilitate accurate claim processing, and offer real-time insights and analytics.

To illustrate the system's effectiveness, Pratik gave an example of how during the COVID-19 pandemic, Signetic supported mass vaccination efforts in partnership with the City of Seattle, Seattle Visiting Nursing Association, Othello, Arlington Pharmacies and various other organizations. He also highlighted the collaboration with Electronic Billing Services (EBS), showcasing the training provided to their staff and the enhancement of billing capabilities.

Overall, the presentation provided a comprehensive overview of the US healthcare system, the critical aspects of medical coding and billing, and the innovative solutions provided by the Signetic Billing System. Pratik’s insights into the current landscape and future directions underscored an in-depth understanding of the system and a commitment to improving efficiency, accuracy, and patient engagement in medical billing with Signetic LLC.

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