Navigating the US Healthcare System:​

Examine the structure of the US health system, payment models, and policy implications. Learn medical coding, billing, clinical guidelines, pharmacology, ethics, EMR usage, and patient demographics.

Explore structure and organization of the U.S. health system, including public programs like Medicare and Medicaid, private insurance and providers, and federal agencies such as CMS, NIH, CDC, and FDA.

Explore health care insurance types—Medicare, Medicare Advantage, Medicaid, and commercial plans—and how federal, state, and private administration shape coverage for 65 and older, and those with end-stage renal disease.

Explain traditional fee-for-service Medicare and Medicare Advantage, outline 65-plus eligibility and disability pathways, and outline parts A–D, Medigap, Tricare, and dual eligible plans.

Medicare Advantage, or Part C, is a private-insurer alternative to original Medicare offering Part A, Part B, and often Part D, with extra benefits like vision, hearing, and dental.

Explore how MSOs manage duties like HR, payroll, compliance, coding, IT services, and supplies, so providers focus on patient care; learn how ACOs coordinate high-quality care under alternative payment models.

Explore fee for service, a traditional payment model where providers are paid for each visit, test, or procedure, with claims submitted and reimbursement tied to quantity over outcomes.

Explore value based care as a patient-centered, outcome based model that links reimbursement to health results, emphasizes care coordination, prevention and early detection, data driven analytics, and quality over quantity.

Explore how managed care coordinates all patient care through PCPs, reduces costs, and sustains high quality, with HMOs and PPOs as primary plan examples.

Capitation pays providers a fixed per-patient amount per period, often per member per month (PMPM), in advance, regardless of services, contrasting with fee-for-service and supporting preventive care and cost control.

Explain how risk adjustment ensures accurate CMS reimbursements by paying plans for the risk of each beneficiary based on health status and demographics.

Explore how RAF risk scores are determined in risk adjustment programs using demographics and diagnoses. Discover why scores reset to zero each January and how they estimate future healthcare costs.

Medicaid is a federal-state program for low-income individuals and families, with state-specific eligibility and benefits, covering nursing home and personal care services not usually covered by Medicare.

Explore commercial health insurance offered by private companies, including premiums, deductibles, co-pays, and co-insurance. Learn plan types such as HMO and PPO, Medicare Advantage, marketplace tiers bronze, silver, gold, platinum.

Explore HMO, PPO, EPO, and PSO types of health insurance, including in-network and out-of-network coverage, referrals, service areas, and provider-sponsored models.

Understand how copays, premiums, out-of-pocket costs, deductibles, and coinsurance determine your healthcare expenses for in-network and out-of-network care.

Demonstrates deductible and coinsurance concepts with concrete cost scenarios, showing how a patient pays upfront deductible, then a coinsurance share, and how the out-of-pocket maximum limits costs.

Navigate in-network vs out-of-network care, where agreements with insurers provide discounted rates for insured members, lowering cost sharing, while out-of-network services lack pre-negotiated rates and may cost more.

Explore the revenue cycle from patient scheduling to reimbursement, including insurance eligibility verification, co-payment collection, prior records, provider assessment and plan, billing audits, payment processing, denials management, and patient collection.

Explore how CPT, ICD-10 codes, and HCPCS categorize and document medical services, procedures, tests, and supplies, with examples like CPT 99201 and HCPCS 90717.

Learn the icd-10-cm code structure—category, etiology, anatomic site, and severity—with distinctions for episodes of care in injuries or external causes, illustrated by s 86 011D a right Achilles tendon strain.

Learn how U.S. clinical guidelines and standards use evidence-based medicine and the scientific method with clinical expertise and patient values to improve health care decisions and outcomes.

Clinical practice guidelines are developed, evidence-based statements guiding diagnostic and treatment decisions. They are not fixed protocols; they reflect systematic reviews and NIH examples such as vitamin D and calcium.

Learn prescribing practices and regulations under federal and state laws, DEA guidelines, and institutional policies; explore prescription monitoring programs and the scheduling of controlled substances.

Explore electronic prescribing, direct to pharmacies via QR verification, emphasizing accuracy, tracking, compliance, and patient education. Follow certified EHR requirements, DEA two-factor authentication, standardized protocols, and thorough patient assessment.

Explain informed consent as a voluntary process based on capacity and comprehension, using plain language, enabling shared decision making and documenting patient autonomy under law.

Explore how medical malpractice and liability arise from diagnostic, surgical, and medication errors, and failures in informed consent. Examine HIPAA privacy and security rules, breach notification, and penalties for non-compliance.

Explore electronic medical records as digital patient charts within a practice. They improve accuracy and legibility, coordinate care, streamline workflows, and enable real-time access via patient portals and electronic prescribing.

Explore telehealth, using telecommunication tech to diagnose, treat, and monitor patients remotely. Expand access and convenience while guiding secure remote care through covid-era guidelines from AMA, ATA, and CMS.

Explore the US patient demographic landscape, highlighting a diverse population, aging trends, urban–rural access, and key metrics on age, gender, race, and poverty.

Explore common diseases and health conditions in the United States, including heart disease, cancer, diabetes, COPD, stroke, obesity, hypertension, arthritis, influenza, pneumonia, and mental health disorders.

Gain insights into the U.S. health care system's structure, payment models, coding and billing, pharmacology basics, ethics, and electronic medical records to improve compliance and patient care.

The impeachment resolutions team thanks you for participating in this course on navigating the U.S. healthcare system; stay tuned for more videos.