Both billing services and large practices usually use the same insurance codes, payment codes, adjustment codes, billing messages, etc. across their client practices.  We wanted MedSuite to provide this capability while only requiring the maintenance of one set of codes for the entire billing service, where possible.  Why make the billing service maintain a complete set of billing messages or payment code for each of their clients when a single set will be sufficient?  These requirements led us to define the concept of a Company.

The data for each company is maintained in a separate database.  This not only allows certain codes to be maintained and shared at the company level, but it also provides the added benefit of physically segregating and securing the data of one company (billing service) from that another, rather than simply separating the data by using a client code of some sort.

The primary objective of MedSuite is to satisfy the practice management requirements of complex physician organizations.  We reasoned that if MedSuite can satisfy the practice management requirements of a complex physician organization, then a simpler organization such as a solo physician in practice or a small group of physicians in practice should be easily satisfied as well.  Let's examine a fairly complicated physician organization:

Assume that there is a group of physicians who call themselves Anesthesia Associates of America.  These physicians may provide services in multiple hospitals and/or surgical centers.  They may provide services for patients in need of anesthesia services, chronic pain management services, and critical care services.  They may be legally organized together in one or more partnerships, professional associations, or professional corporations.  From a legal and tax position, they may function as separate individuals.  They may call themselves "Anesthesia Associates of America" in order to appear to the outside world as a single entity.  They may be multiple legal entities that are divided on physician lines, facility lines, or type of service lines.  The number of ways to divide such an organization is at least equal to the number of physicians in the organization.

We are not really concerned with all of that.  We are only concerned with two fundamental questions:

In MedSuite's nomenclature, the term "practice" performs two functions.  First, it allows us to define the organization called Anesthesia Associates of America as a reporting "roll-up".  Second, and perhaps more importantly, is allows us to greatly reduce the replication of data and ease the maintenance chores within this organization.

A division represents an entity that is formed for the purpose of providing medical services to patients and billing for these medical services to patients and their insurance carriers.  Simply put, in our definition above, a division is a legal entity that has a Tax ID number, files Federal and State income tax returns, receives 1099's from insurance carriers, owns assets including bank accounts and real property, etc.  In short, it is a "business".

In MedSuite's nomenclature, the term "division" performs two functions.  First, it allows us to define the legal entity called Anesthesia Associates of America as a reporting "roll-up".  More importantly, is allows us to separate the financial data of different legal entities that may be operating as a single "practice" but which are actually different businesses whose funds cannot and should not be co mingled.

In the practice example provided previously, Anesthesia Associates of America may be set up as one or more divisions.  All of the services provided by the physicians that comprise the practice Anesthesia Associates of America may be provided by a single legal entity (i.e. division) called Anesthesia Associates of America.  Conversely, the services provided by these physicians may be allocated to several legal entities (i.e. divisions) by type of service and called the Anesthesia Division, Chronic Pain Management Division, and Critical Care Division.  However, the services provided by these physicians could be allocated to several legal entities (i.e. divisions) by the location in which the service was performed and called the Hospital A Division, Hospital B Division, etc.  Practically any reason one can imagine may be used to define the division.  The important fact is that a "practice" may and often does consist of several legal entities.  Our goal is to accommodate this requirement without putting too many unnecessary restrictions in place.

A physician is a person who is licensed to practice medicine by the state in which he is practicing.  A physician is a member of a practice but performs services under the legal umbrella of a division.  Since both the physician and the division are living, legal entities, identifying numbers may be assigned to either the physician or to the physician within a division.  If in our Anesthesia Associates of America example the anesthesia services, chronic pain services, and critical care services were billed under separate divisions, each physician would have a personal social security number, a UPIN, and a state license number.  In addition, in order to bill certain carriers under the division, a physician may also need a number assigned by the carrier for each division.  Examples of this include Medicare numbers, Medicaid numbers, etc.  Physician is a standard sort and control-break function in the software.

An individual who is licensed or certified to assist a physician in the practice of medicine.  An assistant may be a Physicians Assistant, Nurse Practitioner, Certified Registered Nurse Anesthetist, Anesthesia Assistant, etc.

Hospital-based specialties such as anesthesiology lend themselves well to the concept of a "facility".  Under MedSuite's nomenclature, a facility is simply the physical address where a service was performed.  Generally, a facility may be thought of as a "hospital".  However, a hospital may be spread across a large campus with a number of physical locations.  A facility may provide services that are performed in a number of HCFA/CMS Places of Service.  Facility is a standard sort and control-break function in the software.

The place of service (HCFA/CMS) where the service was rendered.  May be the same or a different street address as the facility.

Frequently, the contract between the hospital and the anesthesia practice providing anesthesia services calls for the anesthesia practice to cover a defined number of "rooms" or O/R Suites.  These suites are often not fully utilized.  In turn, this requires that more anesthesiologists will be required to provide anesthesia for the number of surgical cases performed.  Analysis reporting by suite is often required to convince hospital administrators that the staffing model is inefficient and places an unreasonable financial burden on the anesthesiology department.

A patient is the person to whom the physician is providing medical services.  The patient exists at the practice-level and may have multiple sets of active insurance thereby eliminating the need to have multiple "patients" representing the same person.

The person or entity who is legally and/or financially responsible for the patient.

A subscriber is the person who is holds the insurance under which medical services provided to the patient will be billed.  The subscriber and the patient may be one and the same person or they may have some relationship such as spouse, parent and child, or something else altogether.  The subscriber and the account may be one and the same person or they may have a some relationship such as spouse, parent and child, or no relationship at all.  A subscriber exists at the practice-level.

A carrier is an insurance company, health maintenance organization, self-insured corporation, or healthcare intermediary.  Under our definition, a carrier is effectively a reporting entity.  The definition of schedules of benefits, fees, claims processing functions, etc. does NOT take place at the carrier level.  These functions are defined at the plan level.  A carrier may have multiple plans.

The plan is the place where the detail that supports the definition of contract parameters, calculation of billed and allowed fees, and the submission of claims is defined.

A policy is the "intersection" of a plan, a patient and a subscriber.  A policy also maintains other information such as the policy type, policy number, group number, eligibility dates, etc.