Provider-Payer Transactions

Provider-Payer Transactions

Roy Rada (University of Maryland Baltimore County, USA)
Copyright: © 2008 |Pages: 27
DOI: 10.4018/978-1-59904-651-8.ch006
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Abstract

The key financial transactions in U.S. healthcare occur when the provider sends a claim to the payer and the payer adjudicates the claim. This chapter first explains the history of electronic data interchange (EDI) and then shows the powerful, costsaving impact that it can have on healthcare. One bottleneck to EDI in healthcare has been the lack of standardization. This problem was addressed with a law passed in 1996, with which the healthcare industry was still grappling a decade later. The standardization of these transactions will be explored in detail in this chapter. After that, a different aspect of provider-payer transactions is examined, namely, the temptation to cheat and the role of software in combating fraud.

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Table of Contents
Foreword
Ronald L. Gue
Acknowledgment
Chapter 1
Introduction  (pages 1-25)
Roy Rada
Healthcare is one of the greatest single cost items for citizens in many developed countries. Information is fundamental to healthcare. Yet... Sample PDF
Introduction
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Chapter 2
Software Life Cycle  (pages 26-54)
Roy Rada
The traditional software life cycle defined in ISO 12207 (Rada & Moore, 1997) begins with requirements capture and ends with retirement. The system... Sample PDF
Software Life Cycle
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Chapter 3
Providers  (pages 55-85)
Roy Rada
The official definition of a healthcare provider is broad. It encompasses institutional providers such as hospitals, nursing facilities, home health... Sample PDF
Providers
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Chapter 4
Payers  (pages 86-106)
Roy Rada
Most of what has been discussed in this book focuses on the provider and its relation to the patient as regards information systems. However, in the... Sample PDF
Payers
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Chapter 5
Data and Knowledge  (pages 107-142)
Roy Rada
In the 1960s and early 1970s, the emphasis in hospital information systems was on operational control—active monitoring of routine task performance... Sample PDF
Data and Knowledge
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Chapter 6
Roy Rada
The key financial transactions in U.S. healthcare occur when the provider sends a claim to the payer and the payer adjudicates the claim. This... Sample PDF
Provider-Payer Transactions
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Chapter 7
Information Networks  (pages 170-186)
Roy Rada
The connection of components of the healthcare system is a major step in improvement of the healthcare system. Through networking, different... Sample PDF
Information Networks
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Chapter 8
Regulation  (pages 187-195)
Roy Rada
The use of innovative applications of technology in the highly regulated world of medicine requires compliance with various government regulations... Sample PDF
Regulation
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Chapter 9
Privacy  (pages 196-227)
Roy Rada
The contemporary concerns for privacy are not that an official will physically enter and search someone’s house or that the newspaper will take... Sample PDF
Privacy
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Chapter 10
Security  (pages 228-273)
Roy Rada
Privacy and security of health information is a global concern. However, this chapter will focus on approaches to security in the United States. In... Sample PDF
Security
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Chapter 11
Personnel  (pages 274-298)
Roy Rada
Successful information systems depend more on people than on technology. What are the roles that are filled in a healthcare organization? Major... Sample PDF
Personnel
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Chapter 12
Vendors  (pages 299-321)
Roy Rada
A vendor is any person or company that sells goods or services to someone else in the economic production chain. Parts manufacturers are vendors of... Sample PDF
Vendors
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Chapter 13
Diffusion  (pages 322-336)
Roy Rada
To diffuse is to spread widely. Anthropologically, diffusion occurs when practices or innovations spread within a community or from one community to... Sample PDF
Diffusion
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Chapter 14
Conclusion  (pages 338-347)
Roy Rada
Healthcare systems are so connected to the political and economic situation of a country that detailed, practical insights are hard to obtain that... Sample PDF
Conclusion
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