Essential Healthcare knowledge a business analyst should possess for a BA job in

healthcare domain,

 Business analysis is the art of requirements management with the potential support to the whole
of the project life cycle. A potential business analyst candidate will have to the basic knowledge
of requirement methodologies, testing methods, implementation cycle, software development
process framework. If any particular Business analysis certification like ISEB has been done,
then the prospects of the candidate is good for the position of a business analyst. But if the
business analyst position is for a particular domain such as healthcare, then there are lot more
expectations from the business analyst candidate. Healthcare domain is a more complex domain
and requires a good working background in the industry to know in detail its business process
and internal workings.

The healthcare domain requires an in depth knowledge of the workings of the hospitals and
laboratories as there are many intrinsic differences in this industry. There are several political,
socio-economic and legal issue to be taken care of while dealing with the business processes.
Techniques and technologies used in the healthcare domain have undergone a sea of change from
the past few years and the business analyst candidate will have to have a good grasp of these
processes and be technologically sound. The business analyst's job in the healthcare domain is
not only to provide better processes and software packages but also to ensure that the time lines,
cost and accuracy are adhered to as the systems are linked to actual human lives and any mistake,
problem or slip up may result in disaster directly or indirectly.

A healthcare business analyst should have the experience of clinical trial procedures and
terminology with added knowledge in tools like SAS etc beneficial. Expertise or basic
knowledge in clinical research will also help in getting the healthcare domain job for the
prospective business analyst. There are several systems which are enterprise content
management systems, data warehouses storing millions of patient or staff records and medical
data. Also, there are systems which help the medical professionals to make informed decisions.
In case of any mis information there can be resulting fatalities. Its the responsibility of the
business analyst to ensure that the implementation of such systems are fail proof. Another
important attribute of a business analyst in the healthcare domain is discreteness to ensure that
 the lives dependent of such systems are protected. While analyzing requirements for healthcare
related software information security is one of the major issues and the business analyst should
be aware of the importance of the security of the data. Hence, the non functional requirement
specifications which are also documented by the business analyst should clearly list out the risks
and constraints related to the health care domain and should ensure extra layer of information
security if required.

Apart from the functional knowledge of the health care domain, the prospective business analyst
candidate should also be aware of the latest programming languages, business applications, data
mining tools, documentation management and other such technology stuff. So its vital for a
candidate coming for a job in the healthcare domain realizes the nuances of the industry and
hence, should preferably have a solid background in the healthcare domain and if possible at
least  a few years experience as a business analyst

Health care claims tutorial

Healthcare claims cover the risk of sickness and offer the benefits given on the event of
hospitalization, surgery, occurrence of illness etc. The benefits which can be claimed under
healthcare products are:

a)      Outpatient or General Practitioners care – General Practitioners (GP) cater to the primary care
benefits of the patients and if there is any specialist treatment required then the general
practitioner can refer the patient to a specialist doctor/hospital.

b)      Inpatient or Hospitalization including surgery - GP or the Specialist may refer the insured to an
approved hospital. The hospital care includes in-patient treatment and day surgery in the
hospital.

 
c)      Dental will cover the dental benefits like capping, polishing, crowning etc

d)      Maternity will cover the benefits including surgery, miscarriage etc.

Depending on the type of health insurance which has been taken, the insured can select the
benefits he wants to be covered for. There are some health care products which cater to special
illness such as cancer, kidney operations. There also some schemes by which the insurance
companies seek to provide benefits to their customers. One such scheme is the Panel
doctors/hospitals concept. A network of General Practitioners, Specialists, clinics etc can be
grouped by the Insurance Company to form a “Panel of Doctors/hospitals”. So, there are a range
of medical products offered by Insurance companies which provide ease of payment for the
insured if he/she visits panel doctor/hospitals. This range of products will be similar to the
standard health care products like except that the hospital payment can be done by cashless cards
and later the hospitals will reimburse the amount from the Insurance Company. There are also
other benefits which are associated with such schemes.

The insured should be well aware of his covered benefits and his insured period (i.e. the time in
which he will be covered, normally the healthcare products are renewable after one year).
Generally the claims procedure in any insurance company for health care products is as follows:

The insured (client who has taken insurance) on the occurrence of an event (such as illness) can
either approach the insurance company directly or the hospital will do it on his behalf in case of
cashless reimbursement. On receiving the bills and the claim form from the hospital/insured, the
claims executive in the insurance company will evaluate the details and check the eligibility of
the claimant (insured) who has made the claim. The Claimant can be the insured himself or his
dependants. The eligibility is needed to be checked in case there is a claim for benefits for which
he may not be applicable for depending on the benefits terms and conditions. Once the claims
executive has verified the eligibility of the claimant the claims will be processed and the payout
amount will be calculated depending on the amount he is eligible for and the amount he has
incurred (billed amount). After the processing, the payout amount will be forwarded to the
Finance/Accounts department for the final payout via the chosen payment method (can be
cheque, draft or bank transfer)

What is SAS ?
  

Statistical Analysis System (SAS)

 SAS or Statistical Analysis System is provided by SAS institute, headquartered in North Carolina, USA. It’s
an integrated system with software modules which are designed for business intelligence (BI), Customer
Relationship Management (CRM), IT and financial Management and many more. The main purpose of
SAS is to collate, manipulate and present data. Hence, it’s also widely popular as a data and statistical
analysis tool. One of the major advantages of SAS is that it’s highly compatible in many computer
environments, making it suitable to be used for different purposes all over the world.

SAS business solutions help the organizations in transforming enterprise data into strategic information
which in turn will help in the increased performance of the enterprise.       Its products range from
Business Analytics, CRM, and Data Analysis to Performance and Risk management.

SAS can be used across industries and large to small, medium enterprises. Say for example, the use of
SAS Enterprise solution in the Insurance world will ensure better forecast of business trends, provision
of insurance data models which will ensure that the main enterprise systems are integrated. Also, SAS
business solutions provide a business intelligence framework to ensure an end-to-end solution for data
integration, manipulation and storage.

Some of the major solutions offered by SAS software are given as follows:

a)      SAS Analytics - Analytics provides the basis for

         Data mining – the huge volumes of data is synonymous to each and every
organization and to mine to find trends and setup data models is part of the
solution provided

         Data categorization – Automatically categorize huge amounts of content based

         Forecasting – Analyze the patterns and predict the trends

         Statistics – Use statistical models to arrive at strategic information.

b)      SAS Business Intelligence - provides the organization the ability of analyzing and presenting the
data. It has the unique integration with Microsoft Office tools so as to make it more user friendly
in accessing, gathering and manipulating the data.

c)      SAS CRM comprises of the various sub modules such as

         Customer experience analytics –  data collection, analysis and presentation

         Marketing Analysis – impact of the marketing investments and the bottom lines
can be investigated

         Resource management – includes the planning, budgeting and performance

         Decision management – provides real time decisions based on the data collected
on the various media.

d)     SAS Performance Management provides a holistic view to the cost control initiatives,
understanding the business drivers, identifying the business and process risks and how to manage
them as a whole.

e)      SAS Supply Chain Management provides valuable insight to a company’s customer
management, demand forecasting models, supply networks to effectively achieve business
objectives.
The solutions given above are only a subset of the business suite provided by SAS. Even though SAS is
more widely known as the statistical analysis software, it can greatly enhance the workings of an
organization from all modules, departments and systems and help in the progress towards its business
and strategic objectives!

What is clinical trials

Clinical Trials

Clinical trials are research studies that enroll patients to evaluate new treatments which seek to
improve upon existing treatments. Before their use on patients, new therapies are studied
extensively in the laboratory. This preliminary investigation helps select the most promising
treatments and determines the safest and most effective means for administration. Only through
these trials can new information be obtained which can change the standard of cancer care.
Clinical trials are the crucial link between the laboratory and the pharmacy shelves for new
drugs, yet most lay people have little understanding of the process; the average person's exposure
to clinical trials may run no deeper than advertisements soliciting recruits for new studies, which
often offer compensation for participants. The first phase in a clinical trial begins only after
extensive tests have been conducted in the laboratory using tissue cultures, animals or both. The
U.S. Food and Drug Administration (FDA) have enforced a set of guidelines for research on
humans. This set of guidelines is set to begin with a small study of healthy volunteers. Subjects
or volunteers receive closes of the drug being studied, to gauge side effects, determine safe
dosages and observe how the drug is metabolized. In the second phase of a clinical study, the
medication or treatment is administered to a somewhat larger group of people who have the
specific condition it is intended to treat.

If the earlier trials show promise, a third phase involving a large sample group helps researchers
determine with greater precision the drug's efficacy. In investigational trials, scientists may
administer placebos to a control group; often the researchers themselves are not aware of which
patients are receiving the medication or the placebo. FDA guidelines are designed to prevent
abuses of the clinical trial system. Researchers must obtain informed consent before subjects can
be included in clinical trials, meaning that participants must receive adequate information about
the risks and responsibilities involved, and about treatment options available.

Any clinical trial seeking an FDA research permit must also be monitored by an Institutional
Review Board, consisting of at least five people with varying backgrounds which must include a
member from a nonscientific discipline and one not affiliated with the research institution in
question.

Such trials, which can be very costly, are often funded by the drug companies which want to
push the product on to the market. The payoff can be big but very infrequent. The
Pharmaceutical Research and Manufacturers Association in Washington, D.C., estimates that
only five in several thousands of compounds that enter preclinical testing ever make it to trials
involving humans. Of those five, only one will ever reach the pharmacy shelf after the necessary
approvals.  The federal government provides major funding for clinical trials through
organizations such as the National Cancer Institute. But most of such clinical trials are neutral,
i.e. they do not favor any particular pharmaceutical company over another. Thus, clinical trials
are part of the progress we need to make in the world of science and to provide better medical
drugs available to the evolving diseases out in the world!!

Facets tutorials for health care Business Analyst

FACETS

With an ever evolving and growingly complex health care market, what is required mostly is a
software solution that goes beyond normal processing and helps the organization in responding
quickly and effectively to the changes around the market. The software package should help the
organization in achieving its strategic objectives in the industry while ensuring that there are no
compromises on other fronts. The changes can be driven by several factors such as government
regulations, consumerism, and medical cost trends.
“FACETS” is one of such health care administration based enterprise-wide software solution.
This amazing software platform, with deeply integrated applications, automates processes across
your entire enterprise and drives greater cost-efficiencies. FACETS also helps in supporting the
organization in getting the consumer-directed products demanded by today's retail health care
market and deliver advanced care management capabilities.

FACETS can help you maximize the organization’s operational and business efficiencies
through greater automation and enables seamless transactions between the providers (may be
hospitals or doctors, clinics etc), members and within your plan (which is the actual health care
product). The advanced functionalities which are included with FACETS enable health care
plans to achieve operational efficiency while supporting enterprise-wide business initiatives.

“FACETS” is a widely used software solution for health care plan administration and is
currently the leading provider - proven to be the choice for current and emerging business needs
in the health care sector. So, what are the benefits of using FACETS in today’s health care
industry?  We are provided with leading-edge functionality to support key business needs, such
as consumer retail products, HAS (Health Savings Account) and FSA (Flexible Savings
Account) management, Medicare/Medicaid, care management and provider network
management.

It also provides the flexibility to support multiple lines of business, including all commercial
medical markets, commercial specialty markets, consumer-directed, managed Medicaid and
Medicare Advantage. Also, it’s proven to have the required scalability to meet the transaction
needs of the largest health care organizations. But that does not mean it’s not suitable for smaller
or medium enterprises or businesses! The solution is an advanced, enterprise-wide platform to
enable integration with third-party applications for maximum efficiency and competitive
advantage.

It can extend the enterprise beyond traditional borders, with e-business applications that connect
you with key constituents and support online transactions. It can also enable you to receive, store
and send HIPAA-standard transactions and facilitates the administration of HIPAA privacy
rights. On the other hand, FACETS can reduce the administrative costs to 10% or less through
greater auto-adjudication, integrated workflow management and improved operational
efficiencies. It also improves management of the network by effectively administering complex
provider and facility contracts and accurately forecasting the financial impact of proposed rates
and terms. On offer with the software package is the most choices of leading database option
(Sybase, Oracle, or Microsoft SQL Server). So if you are a part of the health care industry and
need an enterprise software solution to help achieve your business needs and streamline your
processes and cater to the regulatory requirements, you need to look no further as FACETS is
the answer to all of this!

Healthcare fraud detection

 
What is health care fraud? It’s a type of fraudulent and criminal activity related to health care
claims in order to make a profit. Healthcare fraud can be done on the part of the provider (i.e.
the hospital or the doctor or even the medical staff involved) or by the client or patient. Most
common type of fraudulent activity in healthcare activities is providing fake bills in order to get
reimbursement either from employer or directly from the insurance company. Due to the level
and dept of penetration there is a huge loss of revenue detected world wise. There are plenty of
opportunities for fraud to happen in the healthcare industry but also plenty of methods for
detecting it. Contemporary healthcare is a multilayered and fragmented enterprise composed of
competing and conflicting payers and participants, each with ample circumstances and motives
to commit fraud. This climate presents both tremendous opportunities and significant challenges
for auditors in the healthcare industry. The unfortunate reality of fraud is that once an asset is
stolen, it is gone. The moral is that prevention is key. Barring major changes in the healthcare
delivery system, however, the main thrust of ensuring payment and service integrity will
continue to be on the back end of the process. This is where the auditors come in. Healthcare
fraud is an evolving concept that responds to antifraud pressures by branching out in new
directions or developing additional defenses against detection and new means of concealment.
Auditors should be alert to these emerging issues and attuned to healthcare market trends with
shifts in risks, opportunities, regulations, and business practices.  It is important to remember
that, in evaluating evidence, not only must auditors exercise professional skepticism; they must
also be prepared to recognize potential fraud. Information technology can be the answer to
detecting such fraudulent activities in the healthcare industry. There are many software packages
and technology trends which are up coming and should provide an answer to at least lessening
such activities, if not completely stopping them. Automated coding software can be studied to
and recommend best practices for the prevention, detection and prosecution of healthcare fraud.
As the healthcare sector embraces electronic health records to reduce medical errors and improve
cost-effective delivery of care, these same technologies have the potential to prevent and detect
healthcare fraud. The major technology approaches from the major players are just very
expensive. The cost of such investments has been very difficult for many companies to get
approved. And most products that are good at spotting such frauds are mostly retrospective. And
it's much harder to get that money back after the check's been sent. It would be beneficial if the
programs could better address fraud prospectively, but then they face trouble from states with
prompt payment laws and HIPAA transaction standards. Clients can have difficulties in
aggressively attacking provider fraud because they need to maintain good relations with their
provider networks. Thus, all we need is the complete cooperation of all parties together with the
right tools to help us curb the healthcare frauds!

What is HIPAA

HIPAA (Health Insurance Portability and Accountability act)

 The Health Insurance Portability and Accountability act( HIPAA) first came into the scene on
August 21, 1996. HIPAA was the result after the following laws were amended:

-        Internal Revenue Code of 1986(IRC),

-        Public Health Service Act (PHSA).

The main intent of HIPAA is to improve the portability and security of healthcare coverage in
the group and individual insurance markets and group health plan coverage provided in
connection with employment. The HIPAA provisions limit the use of preexisting condition
exclusions, guarantee access to health care coverage and renewability of coverage, establish
special enrollment periods, and prohibit discrimination on the basis of health status. All group
health plans are covered by HIPAA, except plans covering fewer than two employees, and
nonfederal governmental plans that elect to be excluded. If a plan administrator does not comply
with HIPAA requirements regarding providing certificates of coverage, limiting preexisting
condition exclusion periods, crediting prior coverage toward the satisfaction of a preexisting
condition exclusion periods, the plan administrator may be subject to a penalty.

HIPAA limits pre-existing condition exclusion periods to 12 months, and plans must reduce that
period by the length of the period during which an individual had prior creditable coverage.
HIPAA prohibits pre-existing condition limits for pregnancy, newborns, and children who are
newly adopted or placed for adoption. The HIPAA provisions relating to preexisting condition
exclusion periods become effective for plan years beginning on or after July 1, 1997. For
collectively bargained plans, the effective date is the later of July 1, 1997, or the ending date of
the last agreements pertaining to the plan. Starting on June l, 1997, a certificate of creditable
coverage must automatically be issued when an individual will lose coverage under the plan.
Therefore, a certificate must be issued when COBRA (Consolidated Omnibus Budget
Reconciliation Act) qualifying events occur, COBRA continuation coverage ends, or
continuation of coverage offered as an alternative to COBRA or in compliance with a state law
ceases.

The certificate will state the period during which the individual and his or her dependents had
coverage including continuation coverage under COBRA or coverage provided as an alternative
to COBRA or in compliance with a state law. The certificate provides the documentation of
"creditable coverage" that a new plan needs in order to give the individual credit for the prior
coverage. The plan administrator will be required to issue the certificates unless an agreement
has been reached between the plan administrator and issuer/insurer for the issuer/insurer to
provide the certificates.

The dependents are entitled to a written certificate of creditable coverage. Loss of eligibility for
coverage includes a loss of coverage due to any of the following events: legal separation;
divorce; death; termination of employment; reduction in the number of hours of employment;
and any loss of eligibility after a period that is measured by reference to any of the foregoing.
Under HIPAA, a group health plan may not establish rules for eligibility to enroll or require any
individual to pay a premium or contribution that is greater than the premium or contribution for a
similarly situated individual enrolled in the plan based on an individual's health status.

Medical procedures policies

Medicaid procedures and policies

Enacted in 1965, Medicaid has become the backbone of USA's health care safety net, providing
health coverage for nearly 59 million low-income Americans, including families, people with
disabilities, and the elderly.  Nowadays, Medicaid provides for almost 30 million children in the
United States and pays for approximately half of all long-term care costs. Those receiving
Medicaid are among the least healthy of the American people. About 68 percent of Medicaid
spending covers services for disabled, blind, and nursing-home-confined elderly. Those
beneficiaries require extremely costly health care. Medicaid is a program jointly funded by the
states and the federal government. Medicaid provides health coverage for children and adults of
low income, medical and long-term care coverage for people with disabilities, and assistance
with health and long-term care expenses for low-income seniors. The mandatory benefits of
Medicaid include physician services, hospital services, family planning, health center services,
and nursing facility services.
The package from Medicaid to benefit children is more comprehensive than the one for adults
because federal law requires states to provide coverage for certain health screenings and
services that are medically necessary. States are normally allowed to provide coverage for
certain other health care services that are approved by the federal government. The optional
services include the benefits such as dental care, fittings for optical, coverage for prescription
drugs, home health care, case management, and rehabilitation services.  The rate of growth in
the Medicaid expenditures is unsustainable and that rapidly increasing health care spending is
"crowding out" spending on other public programs. About 42 percent of Americans living in
poverty are not covered by Medicaid. Most of those uninsured poor do not qualify because they
have no children, they are not disabled, and they are not pregnant. In a family with at least one
parent working full time, only the children are eligible for coverage unless the mother is
pregnant. The father is never eligible.

While Medicare covers virtually everyone over age of 65, only Americans facing severe
deprivation are eligible for Medicaid. Because opinions vary widely about who most needs and
deserves Medicaid, political horse trading and compromises at both the federal and state level
have determined who receives coverage and who does not. The resulting rules of eligibility are
mostly very complex and confusing. To deter the possibility of fraud, applying for Medicaid
requires demonstrating eligibility with financial documents and passing time-consuming and
cumbersome verification checks. The documentation required for such applications are mostly
pay slips to utility receipts to automobile titles and so forth. Some who are eligible do not apply
because of the hassles involved. Others do not apply because they are unaware that they are
eligible. Because of such low rates of reimbursement to doctors discourage them from providing
care to Medicaid patients. About a third of the nation's doctors limit the number of Medicaid
patients they see, and a quarter reports that they will not see Medicaid patients at all. As a
result, such people must rely heavily on care in clinics and hospital emergency rooms and
outpatient departments.