Group Subsgroup Member Class Plan Product Heirarchy

Healthcare insurance Group Plan Class heirarchy in Healthcare (for Business Analysts)

I always get may email from my visitors asking me to explain the hierarchy about different elements in health insurance products.  Usually Business Analysts in any company will have to have an excellent knowledge about Products, Plans, Class, Groups, Sub groups etc.. Because that is what they deal with in their role in any healthcare insurance domain.

Group:

Group is the top most element. Group usually indicates a client for Insurance company. Lets say ABC Electronics is a client of XYZ insurance company, so developers will define the ABC client as a Group. If ABC electronics have different branches in various cities then for ease of maintenance, sub groups are maintained under the main group. Under each sub group Members are created. Members are usually employees of ABC electronics in various states(branches).

These members will be assigned to a Insurance Product (HMO, PPO etc..) in the Insurance company. Usually members will chose or ABC company will allow them to chose as per their designation.

Product and Plan are technically same but some company use different ids for product and plan but their purpose is same. Plan name is mostly used for business purpose.

Each product has to be assigned to a Class. Class explains about which class the employees belong to so he can only chose certain products which are assigned to that class.

So, member is the lowest in the hierarchy (Group-Subgroup- Member).

Product is a separate parallel entity.. as all insurance companies will provider different products/plans to attract subscribers to take their insurance plan.

I hope I have explained upto your expectations, if you have any questions please respond in comments.

10 Healthcare Business Analyst Interview Questions

I often get emails from aspiring Business Analysts those are trying to get a job as a Business Analyst especially in Healthcare Industry like Health Insurance companies. So here I want to list 10 most frequently asked interview questions gathered from Experts in that industry.

1. What are your roles and responsibilities as a Business Analyst?

Well, to answer this question, you need to tell the general roles and responsibilities with respect to Healthcare domain. That means, you need to answer in such a way that the interviewer should get a feel that you really have some good experience in healthcare domain as a Business Analyst. Below are few points to answer this question.

I usually host the meetings with developers, Quality Analysts, Stake holders where we discuss about the current project progress, road blocks and discuss about pending questions that usually need answers from subject matter experts and stake holders. Usually Quality analyst and developers list out some questions while the development work is in progress. As a business analyst I answer the questions. But If I am not sure then I bring these questions in meetings to discuss with stake holders.

We also discuss about existing timelines and if we are on par with the initial time frames, if QA leads ask more time then we discuss the possibilities.

When Testing team test the application they have to send their testcases, test plans to me to review. I as a business analyst review those testcases to see if they meet /cover the business requirements. If not I let them know to write additional testcases to cover those.

I give my daily status to project managers. I also read the CMS.Gov website to update my skills and to know the latest updates in Healthcare industry and government mandates if any.

I gain knowledge in various Fee schedules changes for various states so that the pricing for each healthcare service is to be properly billed by providers and payed by payers.

I also update my knowledge on various new procedure codes, revenue codes and changes in payments in those CPT codes. I let developers and Quality analysts know about any termination of new CPT codes, revenue codes or anything that is important for them to know.

2. What is the importance of use case diagrams in Business Analyst career?

A business analyst must have a a very good understanding of business. Business analyst should know how the business works and know the new changes in business flows. He/She should know the entire hierarchy of the business. But knowing the business does not help unless you can explain that to other teams of the organization. In order to explain in pictorial form, use case diagrams help in a big way. Use case diagrams play important role in Business analyst career and any changes to the business during the course of the project development, the use case diagrams will go through lot of changes and the updated diagrams will be send to all underlying teams.

You may know more about how to draw use case diagrams in our website.

3. What different tools you use most often as a business analyst?

As a business analyst I have excellent knowledge on various tools such as MS Excel, MS Word, HP ALM tool for requirements and testcase documentation. I also have working knowledge on SQL server where I write some sql queries to access database tables.

4. Can you tell some of the important terminologies most widely used in Healthcare domain.

Well in Healthcare domain, we use Class, Plan, Product, Procedure codes, Revenue codes, Diagnosis codes, Providers, Members/Subscribers, Medical claims, Hospital claims, Physicians.

 5. What is the difference between Medical claims and Hospital Claims?

Medical claims are the claims that an insurance company (Payer) receives from a Physician about his services to a patient (Subscriber of the insurance company).

Hospital claims are the claims that an Insurance firm receives from Hospital for the services it rendered to a patient.

6. What are the different types of Claims that an Insurance company receives daily.

Claims are usually will be received in paper form or electronic claims. Paper claims if received from a physician or hospital will be manually entered in the system. If claims are received in electronic form through EDI transactions. Electronic forms are directly will be saved into database in Insurance company.

7. What are the important fields that will be used while dealing Healthcare claims.

Date of service, Procedure code, revenue codes, Diagnosis codes, Price for  each service line, deductible, Copay, Coinsurance, Allowed amount for the claim, Disallowed amount in the total claim, Subscriber, Provider.

8. Can you explain the hierarchy of various important components in Healthcare insurance industry ?

A Group will have various sub groups, and Sub groups will have Subscribers or Members.

Various products are assigned to Class/Plan combinations.

There is an agreement configured for each Provider who is having a contract with that Insurance company.

Every product will have various payment procedures based on copay, deductibles that are particularly assigned to a product.