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Uwe Reinhardt’s important 2003 article in Health Affairs “It’s the Prices, Stupid,” concluded that the difference in healthcare costs between the US and other countries is simply because the prices are higher for healthcare goods and services in the United States. If that explanation sounds a bit weird and unsatisfying, he does go into the long explanation where he names the culprits. As an academic health economist, however, the long answers Reinhardt pens aren’t that much more revealing to the average reader looking for easy-to-talk-about answers.But I’m going to give you something that you can really understand. I’m going to add for comparison, two process diagrams for the healthcare claims adjudication process. The first one is how healthcare claims are resolved in the United States, the second one, is how they are resolved in Canada.So what is ‘claims processing’ and why is it important to the cost of US healthcare? Claims processing is the receipt and adjudication of a claim for a medical service filed by the insured member (that’s you and me) against a third-party insurer (that’s our insurance plan). Claims are accepted or rejected by a Payer (our insurance company) based on the member’s insurance policy. In the US, over 160 million people have their claims adjudicated by private Payers on behalf of millions of employers’ group plans or through individually-owned plans.The commercialization of health insurance creates an almost endless number of different contractual terms and conditions. Each different insurance company (about 4,000 different carriers) processes claims in its own unique way, usually with its own software system. Millions of claims are transacted daily in the US. Each claim can trigger hundreds of actions based on extensive rules and regulations. Insurance companies and clearinghouses designed to help manage claims process many trillions of these actions each year.This ponderous variability across multiple stakeholders (stakeholders are the insurance companies, the drug companies, the plan member/patients, the government, the hospitals, the clinics, the doctors, and other 3rd party providers) makes the US claims payment infrastructure the most complex, the most expensive, and the least efficient claims processing system anywhere in the world. It’s also the reason why the US consumes at least twice as much healthcare administration as any other comparable industrialized country.Fig 1. (below) depicts the Rube Goldberg-esque processing method we've developed in the United States to adjudicate healthcare claims. This image isn't meant entirely to be a lampoon of the system ― it's a true representation of the actual system we use. In fact, the illustration doesn't include nearly enough features; there are layers upon layers of processes and rules that sit below what is shown on top.Fig 1. US Healthcare Claims System InfrastructureNo matter how someone is insured, once they enter the Provider’s system their data must be accounted for somehow, and that’s all reflected in the claims process. Every claims processing software system on the market must attempt to accommodate every possible claims scenario. Most Providers (physicians, clinics, hospitals, etc,) need to be able to claim against each Payer, not just the ones in their ‘network.’ Many claims interact with different programs including Medicare, Medicaid, the VA, and the Affordable Care Act. In addition, different states have different rules and different public and private funding sources. The Payers within those programs all have different claims formats. Providers who send in claims on behalf of their insured patients, must format each claim differently depending on their contract with that Payer, the patient's insurance and the applicable state laws.Incredibly in the US, there is no universal, standard claims format. Some are still even paper-based. Payers struggle with providing the correct contracts to each Provider, and Providers struggle with each different claims format. Mistakes with the first claims submission in some systems are as common as 'clean claims.' Some unethical Payers deliberately make their claims process as difficult as possible, further complicating the process. A mistake at any level kicks the claim out and the process starts over again. Oftentimes, valid claims, once rejected, are not re-submitted for a variety of reasons. Days, weeks, and months may be added to the revenue cycle for Providers due to delayed payments (and unpaid debt has ballooned across every Provider sector since 2015). In many cases, up to 80% of premium costs are spent dealing with claims, not medical care. It's really the convolution of so many variables that makes claims processing in the US an administrative nightmare ― and very close to the chaos it appears to be.The medical billing process is a major driver of healthcare spending in the US. Technology has streamlined many other consumer/industrial sectors; everything from banking, to online purchasing, to media distribution, to ride sharing. But that’s not true for the healthcare claims process. The complexity of the process with its multiplicity of plans and contracts, medical codes, share of government and private funding, multiple accounts to draw from for the same claim, inconsistent deductibles and reimbursement levels, even within the same plan, make it impractical to apply algorithms. Algorithms are computations that deal with finite numbers of precisely defined successive states, eventually producing a final outcome. Algorithms have made consumer-facing companies like Amazon, Facebook, Snapchat, and Uber successful. But health insurance claims are more like snowflakes—no two are exactly the same, making algorithms that depend on ‘sameness’ difficult to adapt. No matter how many feedback loops you build into the process, there continue to be so many computational failures along the algorithmic flow that real humans must intervene every so often to resolve problems and move the claim forward. But human touches are expensive and time consuming — and so far, no application of even the most advanced technology has been able to arrest the continual need to hire more and more administrators.Now let’s look at the same claim adjudication flow for a healthcare system like Canada’s (represented by Fig 2), where every person is covered. Keep in mind that claims for exactly the same medical tests and procedures occur in Canada as the US. On their authority as accredited Providers, Canadian physicians make claims submitted electronically to the provincial health Payer. Adjudication between Provider and Payer happens much the same way as it does in the US. But that’s where the similarity ends because there’s only one plan and one Payer ― no redundant middlemen. In Canada, there's only need for one secure interface between Provider and Payer. To put it into American terms, Canadians are all members of the same plan with the same coverage. The single Payer represents the Insurer, who is dedicated to providing all services to every citizen on an equitable basis.To make a claim for a service provided to a patient, a doctor or his office staff simply enters the provincial tariff codes into a secure electronic database hosted by the Payer. For Providers, there is only one set of prices for each province based on a fee-for-service payment structure. These prices are maintained for years with an annual inflation factor added. For patients, there is nothing to do; no paperwork, no bills. Everyone receives the same comprehensive coverage through their provincial plan based on a system that covers all basic medical services. Because the provincial plan pays, no Canadian has ever been denied care or accumulated personal debt for a medical reason.One Canadian clinic administrator can take care of all of the billing for a group of 10 to 20 doctors along with performing additional office tasks. That's a far cry from the US where it takes 7 administrators to handle the paperwork burden for every 10 physicians. A comparison of hospitals is the best example. It takes about 8 billing clerks to enter billing data for a large ~900-bed Canadian hospital. Contrast that to Duke University where their 957-bed hospital requires the employment of 1,600 billing clerks and an additional unknown number of billing consultants.The administration function is made easier because there’s no such thing as pre-authorization on the front end and the adjudication process for claims is infinitely simpler. Depending on area of practice, 95-100% of claims are paid by the provincial Payer every 15 days. That’s the length of the revenue cycle in Canada — two weeks. The flow chart for the Canadian healthcare system looks like Fig. 2. It's clean, simple, and precise, with no need for any of the billion dollar technology features and onerous government regulations that must be applied to the same adjudication process in the US. And fraud? According to the FBI about $272 Billion worth of medical and billing fraud occurs each year in the US. By comparison, the Canadian system is so simple that fraud is unheard of.Fig. 2 Healthcare Claim Payment Infrastructure in Single Payer SystemThe Canadians have created a plan benefit design that is comprehensive and their laws have given provincial governments the regulatory teeth to make it work. They understand that the more players who are allowed to represent more variable and alterable plans, the more administrative problems it creates for Providers and patients alike. The more Payers and plans ― what we like to call ‘choice,’ in America ― the greater the reduction in cost-effectiveness. Although opponents of 'socialized medicine' typecast it as 'Americans under the thumb of Big Government,' it's impossible to conceive of a system that's more bureaucratic, wasteful and corrupt than what we have now.That bureaucracy means that here in the US, all stakeholders are continually hiring more low-level clerks and administrators to manage the choke-points. (Fig 3. below) In this scenario there is no need for more physicians who would only generate more paperwork ― best to curtail the care to lessen the admin burden, and raise prices to pay for the new hires. Healthcare stakeholders have placed higher value on a good revenue cycle strategy than the delivery of healthcare itself. The result? Higher healthcare premiums, higher co-pays, more high-deductible plans, a high rate of inflation that guarantees significantly higher insurance plan costs each year, and far less coverage than ever before. The other result that’s perversely and indefensibly higher is insurance company profitability along with the billions of dollars in performance bonuses ‘taken’ by CEOs who somehow believe they deserve them. It doesn't matter that the insurers have failed spectacularly in their mission to provide affordable and comprehensive plans to Americans. It only means that ‘whoever has the gold makes the rules.’Fig. 3 Growth in Physicians and Administrators US Healthcare System 1970-2017According to a Harvard study, we put up with $60 billion in overpayments (Americans being charged and paying more than they should have been billed) Annual care for the uninsured and under-insured generates $85 billion in uncompensated costs covered by us, the taxpayers. There are $272 billion in medical billing fraud each year. That means the American system 'absorbs' more in unrecoverable costs due to fraud each year than the entire Canadian healthcare system costs to run! (absorbs = recovered out of higher premiums we all pay) There are also $262 billion in medical claims that are denied, leaving patients to scramble to either get the denial decision reversed or find an alternate means of financing their care. Physicians give away $125 billion in free services for rejected claims each year. Uncompensated care provided by American hospitals is over $38 billion per year. All told, the ‘waste, fraud, and abuse’ measure has been accurately authenticated at around $1.1 trillion of our $3.6 trillion healthcare system.Attempts to reclaim these losses add untold billions in administrative costs, not to mention the millions of hours of unpaid time spent by patients’ families attempting to get the medical care they need. In fact, every pointless and unnecessary cost in the system is recovered on the backs of Americans ― you and me. That’s because insurers don’t endure the cost; they simply recoup losses by increasing premiums, raising deductibles and decreasing coverage.Through all of this, it's key to remember that the number of uninsured Canadians is zero, and the personal debt accumulated for insured medical care is zero. Because the provincial plan pays, no Canadian has ever been denied care. Canada can offer this to everyone because they've wrestled their costs to the ground. Canada and Scotland have the lowest hospital administration costs in the world. There is much to be said about the simplicity and practicality of viewing healthcare as a right, and not a commodity.If a picture is worth a thousand words, then the two comparative process diagrams I’ve illustrated surely provide an eloquent answer to our healthcare problems. But the gains found by eliminating the tortuous claims process only occurs by moving to a simpler system. It’s time to take a serious look at how other countries deliver healthcare for half of what we pay before the harm the current system inflicts upon the country becomes an unrecoverable condition.

Health care costs affect the economy, the federal budget, and virtually every American family’s financial well-being. Health insurance enables children to excel at school, adults to work more productively, and Americans of all ages to live longer and healthier lives. The Affordable Care Act (ACA), has made substantial progress in addressing the uninsured Americans. Americans can now count on access to health coverage throughout their lives, and the federal government has an array of tools to bring the rise of health care costs under control.There are several companies which provide health insurance to the US citizens under the ACA, which in-turn promotes Medicaid and Medicare government programs. According to these programs and their respective market shares, the best positioned health insurers are:-UnitedHealth Group Inc.Humana Group Inc.Anthem Inc.These insurers have been working in developing a high-quality, affordable and accessible health care system.In this answer, I will be assessing the progress these companies have made towards improving the US health care system and discuss how policy makers can build on that progress especially under the Trump administration.Medicare ProgramMedicare is a national social insurance program administered by the US federal government since 1966, currently using about 30–50 private insurance companies across the United States under contract for administration.UnitedHealth Group Inc. provides mainly three plans under the Medicare program.Medicare Part A (hospital)Medicare Part B (doctor and out-patient)Medicare Part C, a type of health plan ,also known as Medicare Advantage Plan. This plan combines the Medicare Part A and Medicare Part B, then provide additional benefits that contribute to improving your health and wellness.It also provides other Medicare Advantage plans which include prescription drug coverage (Medicare Part D). Enrollment in Medicare Part A and Medicare Part B is necessary to be eligible to enroll in this plan. It is necessary to continue paying your Medicare Part B premium to keep your coverage under this group-sponsored plan. UnitedHealth tries to offer coverage that is as good as Original Medicare. The government pays them a fixed fee for one’s care. UnitedHealth is required to handle the payments to doctors and hospitals.Humana Group offers the Medicare Savings Program (MSP) to Medicare beneficiaries whose income falls below $1,357 per month for single individuals and $1,823 per month for married couples.Humana offers several other plans under Medicare, one of which is the Humana Gold Choice plan. Humana Gold Choice is a Medicare Advantage private fee-for-service (PFFS) plan. Humana Gold Choice PFFS allows members to use any provider, such as a physician, hospital or any other Medicare provider in the US that agrees to treat the member after having the opportunity to review these terms and conditions of payment, as long as the provider is eligible to provide health care services under Medicare Part A and Part B or eligible to be paid by Humana Gold Choice PFFS for benefits that are not covered under Original Medicare.Anthem Inc. (Wellpoint Inc. Group) has been focusing on making sure that the needs of the people under the Medicare Program are addressed.Anthem has health plans that support those who are Medicare eligible by developing HMOs and PPOs specific to Medicare and providing Medicare Supplement plans to those who want them. They have been constantly working on expanding the tele-health options.Consumers’ costs concerns are addressed with Dual-Eligible Special Needs Plans (DSNPs) that are primarily $0 premium plans with $0 copays. They include dental and vision coverage and some even include coverage for over-the-counter drug costs. HMOs and PPOs specifically focused on accommodating the needs of the Medicare population are now available in targeted markets in 22 states. In specific markets in California and Texas, Anthem’s Medicare Select plans feature tight-knit provider collaboration. Also, convenient online doctor visits are available to most of Anthem’s affiliated Medicare Advantage plans through LiveHealth Online.Medicaid ProgramMedicaid in the United States is a social health care program for families and individuals with limited resources. Medicaid coverage is low cost or no cost to you. It is health care coverage for people with low incomes. Pregnant women, children, the elderly and people with a disability may qualify for the Medicaid Program.Medicaid Program discussed below is in reference with the state of Florida.UnitedHealth Group Inc. With growth in the Medicaid market, UnitedHealth took a vital step of launching a mobile app to better connect with people covered by the state-federal health insurance program.The new app called ‘Health4Me’ lets people in the state of Florida use their phones to more easily review their case history, track claims and find a doctor. The app also provides a digital health plan ID card, which has proved to be the most popular feature in early testing. It’s more about improving the way we share information than anything else when we decided to launch this for our Medicaid population.Expansion of Medicaid eligibility due to the federal health law has been a key factor in enrollment growth across the country, although some states have elected not to expand their programs. In 2014, about 5.1 million individuals were covered through Medicaid health plans at UnitedHealth and during the first half of 2015, the figure grew by 155,000.Humana Group has offered Medicaid services since 1970 in Florida. It is funded by both the state and federal governments and includes both capitated health plans as well as fee-for-service coverage. The Agency for Health Care Administration (AHCA) is responsible for administering the Medicaid program and to administer contracts, monitor Health Plan performance and provide oversight in all aspects of Health Plan operations. The state has sole authority for determining eligibility for Medicaid and whether Medicaid recipients are required to enroll in, may volunteer to enroll in, may not enroll in a Medicaid health plan or are subject to annual enrollment. The 2011 Florida Legislature passed House Bill 7107 to establish the Florida Medicaid program as a statewide, integrated managed care program for all covered services. This program is referred to as the Statewide Medicaid Managed Care (SMMC). In addition, Humana has the responsibility to ensure providers’ submission of encounter data is accepted by the Florida Medicaid Management Information System and/or the State’s encounter data warehouse.The Florida Managed Medical Assistance (FMMA) program focuses on four key objectives in order to support successful implementation:Preserving continuity of care.Requiring sufficient and accurate networks under contract and taking patients, allowing for an informed choice of plans for recipients and the ability to make appointments.Paying providers fully and promptly to preclude provider cash flow or payroll issues, and to give providers ample opportunity to learn and understand the plan’s prior authorization procedures.Coordinating with the Choice Counseling Call Center and website operated by the Agency’s contracted enrollment broker.Anthem Inc. has been investing significant time and resources to understand and serve the nearly 5.9 million plan members in state-sponsored programs across the country. While focusing on the needs of individual consumers, our plans are seeking out new and better ways to improve health outcomes with high-quality, cost-efficient programs that help society more broadly.Florida ranks first in the nation in the number of newly diagnosed HIV infections and second in the number of pediatric HIV cases reported. Clear Health Alliance, an HIV/AIDS Medicaid specialty plan offered by Simply Healthcare Plans, is addressing the special needs of those living with HIV/AIDS in Florida by offering bundled services tailored to their treatment requirements. Anthem is equipping consumers with the knowledge and support to better manage their health.Commercial Business ModelsUnitedHealth Group Inc.The UnitedHealth Group is a leading diversified health and well-being company that provides health benefits and health services through UnitedHealth and Optum business segments. UnitedHealth provides health benefits services to individual consumers, governments, and employers of all sizes. Optum offers health services to diverse stakeholder groups that include individuals, employers, governments, healthcare providers, payers, and life sciences companies.UnitedHealth Group Business Model EvolutionThe chart shown below is a one year stock market analysis till January 2017.The Insurance Company saw an enormous rise in the revenues and made a large operating profit.Humana Group Inc.Humana Inc. is a for-profit American health insurance company based in Louisville, Kentucky. As of 2014 Humana has had over 13 million customers in the U.S. reported a 2013 revenue of US$41.3 billion and has had over 52,000 employees. It has been the third largest health insurance in the nation.Following is the Financial Highlights of Humana Inc. The results have been extremely supreme over the years!Stock market of Humana Inc. over the last year:Anthem Inc.Anthem Inc. is an American health insurance company founded in the 1940s, prior to 2014 known as WellPoint, Inc. It is the largest for-profit managed health care company in the Blue Cross and Blue Shield Association. It was formed when Anthem Insurance Company acquired WellPoint Health Networks, Inc. with the combined company adopting the name WellPoint, Inc. trading on the NYSE for the combined company began under the WLP symbol on December 1, 2004. On December 3, 2014, WellPoint changed its corporate name to Anthem Inc, and its NYSE ticker changed from WLP to ANTM.Financial Highlights of Anthem Inc. for the past years:Financial and Membership Highlights:(The information presented below is as reported in Anthem’s 2015 Annual Report.)Data Sources:How UnitedHealth Group Makes Money? - Revenues & ProfitsUnitedHealthcare launches Medicaid AppHumana Medicare and Medicaid InformationAnthem, Inc | Investor Relations | Annual ReportsAnthem Annual ReportMedicaid - WikipediaMedicare - WikipediaImage SourcesUnitedHealth Group Incorporated (UNH) Stock ChartGoogleGoogle Images2015 Annual Review UHC

Stages to become a Company Secretary:The student who would like to join the Course after 10+2 pass or equivalent has to undergo three stages to pursue the Company Secretaries Course i.e.Foundation ProgrammeExecutive ProgrammeProfessional ProgrammeThe Student who would like to join the Course after passing the Graduation has to undergo two stages of the Company Secretaryship i.e.Executive ProgrammeProfessional ProgrammeFoundation Programme which is of eight months duration can be pursued by 10+2 pass or equivalent students of Arts, Science or Commerce stream (Excluding Fine Arts)Executive Programme can be pursued by a Graduate of all streams except Fine Arts.Professional Programme can be pursued only after clearing the Executive Programme of CS CourseADMISSION TO THE CS COURSE is open throughout the year. Examinations are held twice a year in June & December.Cut off dates for admission to CS course: .For Foundation Programme-31st March for appearing in December Examination in the same year30th September for June Examination next yearFor Executive Programme28th February for appearing in both modules in December Exams in the same year year31st May for appearing in single module in December Examination in the same year31st August for appearing in both modules in June Exam in the next year30th November for appearing in single module in June Examination in the next year.SUBJECTS FOR CS COURSEThere are 4 papers in CS Foundation ProgrammeThere are 7 papers divided into 2 Modules in CS Executive Programme (wef. 01.02.2013)There are 8 papers divided into 4 Modules in CS Professional ProgrammeSUBJECTSFoundation Programme [4 papers]Business Environment & EntrepreneurshipBusiness Management, Ethics and CommunicationBusiness EconomicsFundamentals of Accounting and AuditingExecutive Programme [7papers]Module I(4papers)Company LawCost and Management AccountingEconomic and Commercial LawsTax Laws and PracticeModule II(3 papers)Labour and General LawsProfessional Program ( new syllabus – w.e.f. 1st September 2013 )MODULE 11. Advanced Company Law and Practice2. Secretarial Audit, Compliance Management and Due Diligence3. Corporate Restructuring, Valuation and InsolvencyMODULE 24. Information Technology and Systems Audit5. Financial, Treasury and Forex Management6. Ethics, Governance and SustainabilityMODULE 37. Advanced Tax Laws and Practice8. Drafting, Appearances and Pleadings9. Electives 1 out of below 5 subjects9.1. Banking Law and Practice9.2. Capital, Commodity and Money Market9.3. Insurance Law and Practice9.4. Intellectual Property Rights - Law and Practice9.5. International Business-Laws and PracticesFee Structure for CS CourseCS Foundation ProgrammeRs.4500/-CS Executive ProgrammeRs.9000/- for Commerce Graduates / CPT passed of ICAI / Foundation passed of ICAI-CMARs 10,000/- for Non Commerce StudentsRs 8,500/- for CS Foundation passed studentsCS Professional ProgrammeRs.12,000/-Examination1. Examination is conducted twice a year in June and December2. Examination feeFoundation Programme -Rs. 1200/-Executive Programme - Rs. 1200/- per ModuleProfessional Programme -Rs. 1200/- per ModuleLast date for submission of application for appearing in the examination25th March (with late fee of Rs. 250/- till 9th April)25th September (with late fee of Rs. 250/- till 10th October)Medium of ExaminationThe Institute allows facility to students to appear in examination in English as well as in Hindi. (Except Business Communication subject of Foundation Program)Qualifying MarksA candidate is declared to have passed the Foundation / Executive / Professional examination, if he/she secures at one sitting a minimum of 40% marks in each paper and 50% marks in the aggregate of all subjects.Time limit for completing CS ExaminationA student is required to complete the Executive and the Professional examination within the registration period. However, on payment of requisite fees the validity of registration may be renewed / extended for further period subject to fulfilling the applicable guidelines.ICSI ORAL TUITION GUIDELINES / PPP GUIDELINES:Salient features of the Oral Tuition Guidelines & PPP Guidelines: Under the revised guidelines 30 lectures of 2 hours duration for each subject of Foundation / 35 lectures of 2 hours duration for each subject of Executive / 40 lectures of 2 hours duration for each subject of Professional Programme has been made mandatoryExisting Practical experience and training requirementsThe students are required to undergo the following trainings:1. 7 days Student Induction Programme (SIP)- within six months of Registration to Executive Programme or exempted therefrom for becoming eligible to seek enrolment to appear in Executive Program Examination.2. 70 hours compulsory computer training program- for becoming eligible to seek enrolment to appear in Executive Program Examination.3. 8 days Executive Development Programme (EDP) - after passing the Executive Programme and before commencement of 15 months training.4. 25 hours of Professional Development Programme (PDP) during 15 months training5. 15 months training after passing the Executive Programme or Professional Programme on completion of Student Induction Program and Executive Development Program with companies and Company Secretaries in Practice registered with the Institute for imparting training6. 3 months practical training is required to be undergone by the student if the student completes professional program examination and exempted from undergoing at least 12 months training on the basis of Company Secretaries Regulations,1982, as amended on submitting the documents to the Institute and fulfills the requirement of Regulation 48. This training will be exempted to the students who have undergone 15 months training.7. 15 days training in a specialized agency such as Registrar of Companies (ROC) / Stock Exchange / Financial and Banking Institution/Management Consultancy Firm can only be commenced if the student completes SIP,EDP , 15 months training and having passed professional program examination.8. 15 days Management Skills Orientation Programme (MSOP)- after Professional Programme and on completion of Executive Development Program and 15 months training1. The students can be exempted from undergoing training totally or partially depending on the practical experience possessed by them on fulfilling the requirement of the Company Secretaries Regulations,1982, as amended, on submitting the relevant documents.2. A student after passing the Professional Programme may enroll as ‘Licentiate ICSI’ at his/her option until completion of training requirements.