Blog Posts by Shaun

  • Understanding the Final Ruling on Medical Loss Ratio

    On December 2, 2011, the U.S. Department of Health and Human Services released its final ruling on the Medical Loss Ratio.

    What does the Medical Loss Ratio final ruling say?

    Effective January 1, 2012, the Affordable Care Act will require health insurance companies, operating in individual and small group markets, to spend at least 80% of the collected premium dollars on medical care and quality improvement initiatives. Health plans operating in large group markets need to expend minimum 85% of the collected premium amounts on administering medical care and quality improvement programs. Not only that, Insurance companies need to submit annual Medical Loss Ratio (MLR) data reports to HHS, so that residents of all U.S states can gauge their return-on-investment on the various health plans offered by different health carriers located in their states. Beginning 2012, insurance companies that fail to comply with the MLR regulation, will need to pay rebates to their consumers before August

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  • Healthcare IT: An Emerging Sector

    The importance of healthcare IT companies have grown manifold after the new healthcare Act emphasized on the importance of technology in healthcare and made mandatory the use of certain software and technology in the health sector.

    However healthcare IT is a relatively new industry and most companies are start-ups. The Affordable Care Act may have given the industry but the success of a healthcare IT company will depend on a lot of other factors.

    - Healthcare is an amalgamated market of various small sectors particular diseases, cures, healthcare providers, information technology, healthcare software, insurance, etc. Each of these is a separate industry in itself and what works for one may not work for the others. Companies will have to develop separate ideas and business plans to deal with each of these sub sectors.

    - Healthcare IT is neither healthcare nor IT. Healthcare IT companies need to understand their domain completely. The regulations are stricter and the guidelines

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  • The Importance of Electronic Health Records

    The advent of healthcare IT in the health industry has ensured that prior health technologies such as paper records are outdated. The health reforms have added to the importance of healthcare software. Technology in the healthcare sector has contributed immensely in providing accurate, reliable and timely service.

    Electronic Medical Records (EMR) and Electronic Health Records (EHR) are basic health softwares that help in doing away with the disadvantages that paper records had.

    The biggest advantage of electronic information is the ease with which it can stored and accessed. Some of the other benefits of EMR are:

    1. Immense information can be stored, managed and retrieved whenever required.
    2. Mishandling, confusion and error associated with manual handling of information can be reduced or even eliminated.
    3. When information is stored electronically, it is easier to keep it confidential when required. This may be needed in cases of storing sensitive data about a patient's

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  • Benefits and Drawbacks of Electronic Health Record

    Electronic Health Record or EHR as they are more popularly known have emerged as the most needed and the most basic healthcare software. EHR have proved to be the backbone of the health insurance exchange and health information exchange. The medical information stored in the EHR is sourced by the exchange platforms to give more information about insurance and health plans.

    Though storing of information in electronic form is always a good idea, it has its side effects too. Here is a look at some of the benefits and disadvantages of adopting Electronic Health Records.


    1. Though the process of converting paper records to EHR may seem costly, the National Health Accounts will have some major savings up it sleeves. This could in turn be invested in better healthcare facilities and government sponsored health insurance programs. After the implementation of the EHR, Medicare will be able to receive about $23 billion more in federal funding.
    2. With the EHR getting implemented

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  • EMR is the building block for healthcare softwares

    The Patient Protection and Affordable Care Act encourages the optimum use of technology in providing healthcare to the residents. A well maintained database of health records is the first step in integrating technology in the healthcare and health insurance sector.

    Electronic Medical Record (EMR) is a healthcare software that precisely addresses this problem of storing the medical information of every individual. An EMR, as defined by the National Alliance for Health Information Technology (NAHIT), is an electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual's health and care.

    The biggest advantage of EMR is that it is much easier to maintain the data and it can be accessed easily by anyone who is authorized to do so. It saves time and money as patients do not have to undergo repeated tests when they change doctors. Also in cases

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  • A Framework of Health Insurance Exchange

    The Patient Protection and Affordable Care Act will soon make it mandatory for all states to have a state-based health insurance Exchange. These Exchanges will be federally funded and will serve as a regulated shopping arena where health insurance plans are bought and sold.

    The health insurance though governed by the state authorities will be funded by federal dollars. Hence, all states Exchanges have to follow a few guidelines that are mandated by the federal government. Some of these requirements are:

    - Has to inspect policies to make sure that each health plan displayed on the Exchange adhere to the standards set by federal and state insurance regulatory bodies
    - Needs to ask for a justification from health insurance companies when there is an unreasonable rise in premiums. The Exchange even has the power to disqualify a company from the online platform if it finds the explanation unsatisfactory.
    - For those who do not have access to the Internet, the Exchange must provide other

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  • Guide to Different Kinds of Healthcare Softwares

    The importance of healthcare software has increased manifold after the Patient Protection and Affordable Care Act has come into enforcement. Different healthcare softwares are being developed day after day to facilitate the changes that the healthcare reforms will usher in. The healthcare insurance softwares available currently are quite flexible and can be customized to meet the needs of health insurance companies and insurance carriers and other Third Party Administrators.

    Individual insurance softwares facilitate the working of a wide range of life insurance products. These softwares provide end-to-end solutions at every step when a customer is purchasing health plans from an online portal. These include technical support for underwriting, processing, policy services, billing, management, advances and commissions, accounting and the likes. Individual insurance softwares cater to those online portals that offer individual and family health plans.

    For those portals that specifically

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  • The Role of States in Health Insurance Exchanges

    Florida was the first state. Others followed. And now almost every state has filed a lawsuit against the federal health reforms. While the law is still being debated in the courts, the federal government has made it clear that it is the state that will be in complete control of the insurance reforms in general and the Exchanges in particular.

    In a statement, US Secretary of Health and Human Services, Kathleen Sebelius has said, "The Affordable Care Act puts states in the driver's seat because they often understand their health needs better than anyone else - and that is why it is so frustrating to hear opponents of reform falsely attack the law as 'nationalized health care'. The truth is that states aren't just participating in implementation of the law; they're leading it."

    It is through these state based Exchanges that a majority of the residents and small firms of the state will purchase their medical policies. The health insurance Exchange will enable the residents to pool their

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  • ICD 10 Proves to be a Major Step Forward in Healthcare Software

    ICD 10 or the International Statistical Classification of Diseases and Related Health Problems is a way to code diseases, signs, symptoms, findings, causes of injury and diseases, as classified by the World Health Organization (WHO).

    The greatly expanded ICD 10 will replace the ICD 9, which contains only 17000 codes and is considered outdated because of its limited ability to accommodate new procedures and diagnoses. However, the reason why ICD 10 is in news is the new Affordable Care Act that will make it pertinent for technology companies to integrate the ICD 10 coding into the Exchange portal.

    The United States will begin official use of ICD-10 on October 1, 2013, using Clinical Modification ICD-10-CM for diagnosis coding and Procedure Coding System ICD-10-PCS for inpatient hospital procedure coding. All HIPAA "covered entities" must make the change; a pre-requisite to ICD-10 is the adoption of EDI Version 5010 by January 1, 2012. The implementation of ICD-10 has already been

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  • Hurdles that the State Health Insurance Exchanges could face

    It is anticipated that the state health insurance Exchanges will forever change the way Americans look at their health policies. But to say that the Exchanges have everything right going for them would be far-fetched statement. The Exchanges are sure to bring about a drastic change in the world of health insurance, but the government might end up facing a few hurdles before it effectively implements these state based online insurance marketplaces.

    The governance of the Exchange is a major concern. The Exchange will be funded by federal dollars. It has to meet the guidelines set by the federal as well as the state government. So should it governed by a body that represents both the parties? Or should a non-profit entity be handed over the charge of administration? Governing a regulated insurance marketplace, and more importantly, who is in charge of the job will perhaps be one the first few problems that the Exchange has to deal with.

    The insurance is a regulated market place for the

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