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Managed Health Care
In the United States, managed care or managed healthcare is a group of activities intended to reduce the cost of providing health care and providing health insurance while improving the quality of that care. It has become the predominant system of delivering and receiving health care in the United States since its implementation in the early 1980s, and has been largely unaffected by the Affordable Care Act of 2010. ...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, s ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Health Care
Health care, or healthcare, is the improvement or maintenance of health via the preventive healthcare, prevention, diagnosis, therapy, treatment, wikt:amelioration, amelioration or cure of disease, illness, injury, and other disability, physical and mental impairments in people. Health care is delivered by health professionals and allied health professions, allied health fields. Medicine, dentistry, pharmacy, midwifery, nursing, optometry, audiology, psychology, occupational therapy, physical therapy, athletic training, and other health professions all constitute health care. The term includes work done in providing primary care, wikt:secondary care, secondary care, tertiary care, and public health. Access to health care may vary across countries, communities, and individuals, influenced by social and economic conditions and health policy, health policies. Providing health care services means "the timely use of personal health services to achieve the best possible health outcom ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Disease Management (health)
Disease management is defined as "a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant."Congressional Budget OfficeAn analysis of the literature on disease management programs. 2004-10-13. Retrieved 2008-10-13. For people who can access healthcare practitioners or peer support, disease management is the process whereby persons with long-term conditions (and often family/friend/carer) share knowledge, responsibility and care plans with practitioners and/or peers. To be effective it requires whole system implementation with community social support networks, a range of satisfying occupations and activities relevant to the context, clinical professionals willing to act as partners or coaches, and on-line resources which are verified and relevant to the country and context. Knowledge sharing, knowledge building and a learning community are integral to the concept of disease management. I ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Prior Authorization
Prior authorization, or preauthorization, is a utilization management process used by some health insurance companies in the United States to determine if they will cover a prescribed procedure, service, or medication. Overview Prior authorisation is a check run by some insurance companies or third-party payers in the United States before they will agree to cover certain prescribed medications or medical procedures. According to insurance companies the reasons they require prior authorizations include age, medical necessity, checking for the availability of a cheaper generic alternative, or checking for drug interactions. There is controversy surrounding prior authorisations and public opinion does vary about why insurance providers require it. The primary controversial reason is that it benefits some insurance companies as they allegedly avoid paying for expensive patient treatments and increase business profits at the expense of patient health. A failed authorisation may re ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Utilization Management
Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers, particularly health insurance companies, to manage the cost of health care benefits by assessing its medical appropriateness before it is provided, by using evidence-based criteria or guidelines. Critics have argued that if cost-cutting by insurers is the focus of their use of UM criteria, it could lead to healthcare rationing by overzealous denial of care as well as retrospective denial of payment, delays in care, or unexpected financial risks to patients. Aspects Utilization management is "a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision," as defined by the Institute of Medicine Committee on Utilization Management by Third Parties (1989; IOM is now the Nat ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Balance Billing
Balance billing, sometimes called surprise billing, is a medical bill from a healthcare provider billing a patient for the difference between the total cost of services being charged and the amount the insurance pays. It is a pervasive practice in the United States with providers who are out of network, and therefore not subject to the rates or terms of providers who are in-network. Balance billing has a variable prevalence by market and specialty. Advocates of balance billing argue that it increases the incomes of high-quality healthcare providers and measures their dissatisfaction with insurance company fees. Critics say that balance billing lets providers raise charges through stealth rather than transparent pricing, creates unnecessary administrative costs and patient confusion, and allows providers to simply pass along costs to patients, rather than helping them to secure good value. It is thought to erode political consensus in favor of a one-tier system of healthcare, and to ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Blockchain
The blockchain is a distributed ledger with growing lists of Record (computer science), records (''blocks'') that are securely linked together via Cryptographic hash function, cryptographic hashes. Each block contains a cryptographic hash of the previous block, a Trusted timestamping, timestamp, and transaction data (generally represented as a Merkle tree, where Node (computer science), data nodes are represented by leaves). Since each block contains information about the previous block, they effectively form a ''chain'' (compare linked list data structure), with each additional block linking to the ones before it. Consequently, blockchain transactions are resistant to alteration because, once recorded, the data in any given block cannot be changed retroactively without altering all subsequent blocks and obtaining network consensus to accept these changes. Blockchains are typically managed by a peer-to-peer, peer-to-peer (P2P) computer network for use as a public distributed led ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Centers For Medicare And Medicaid Services
The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the Children's Health Insurance Program (CHIP), and health insurance portability standards. In addition to these programs, CMS has other responsibilities, including the administrative simplification standards from the Health Insurance Portability and Accountability Act of 1996 (HIPAA), quality standards in long-term care facilities (more commonly referred to as nursing homes) through its survey and certification process, clinical laboratory quality standards under the Clinical Laboratory Improvement Amendments, and oversight of HealthCare.gov. CMS was previously known as the Health Care Financing Administration (HCFA) until 2001. CMS actively inspects and reports on every nursing home in the United States. This includes mai ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Envision Healthcare
Envision Healthcare is a United States healthcare company and national hospital-based physician group. History In December 2016, Envision and AMSURG merged, and shortly thereafter the company's stock replaced Legg Mason in the S&P 500 index. In 2017, the company's subsidiary EmCare, came under scrutiny due to healthcare consumers being shocked by high medical bills from Envision's out-of-network healthcare providers. In August 2017, Envision sold its ambulance unit, American Medical Response, for $2.4 billion to KKR, which it subsequently merged with a similar company it had already owned. In 2017, the company reported a net loss of $232.5 million on revenue of $7.8 billion. In June 2018, KKR announced that it was acquiring the rest of Envision for $9.9 billion, including the assumption or repayment of debt. In February 2020, Envision appointed Jim Rechtin as CEO. In April 2020, they were considering bankruptcy. In October 2020, it was announced that Cigna and Envisi ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
UnitedHealth Group
UnitedHealth Group Incorporated is an American Multinational corporation, multinational for-profit company specializing in health insurance and health care services based in Eden Prairie, Minnesota. Selling insurance products under UnitedHealth Group#UnitedHealthcare, UnitedHealthcare, and health care services under the Optum brand, it is the List of largest companies by revenue, world's seventh-largest company by revenue and the largest health care company by revenue. The company is ranked 8th on the 2024 Fortune Global 500, ''Fortune'' Global 500. UnitedHealth Group had a market capitalization of $460.3 billion as of December 20, 2024. UnitedHealth Group has faced numerous investigations, lawsuits, and fines—including U.S. Securities and Exchange Commission, SEC enforcement for stock option backdating, Medicare (United States), Medicare overbilling, unfair claims practices, mental health treatment denials, and Anti-competitive practices, anticompetitive behavior—highlightin ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Reference Price
A reference price (RP) is the price that a purchaser announces that it is willing to pay for a good or service. It is used by high-volume purchasers to inform suppliers. RP requires consumers to have access to price and quality information, which is not general practice in many industries. Further, it does not help consumers with urgent needs, cognitive and/or other impairments. Reference pricing requires sufficient competition. Otherwise, consumers have no choice about providers, who in turn face less pricing pressure. Reference pricing could encourage lower quality. "Reference price" in this context is distinct from its use in behavioral pricing scholarship. In that literature, a "reference price" refers to a mental standard of comparison or a posted statement of "normal" prices used to judge whether an offered price is good deal – as in "Was $100, now $70." Reference prices in this context are related to work by Nobel Prize winner Richard Thaler on "transaction utility" in h ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Indemnity
In contract law, an indemnity is a contractual obligation of one party (the ''indemnitor'') to compensate the loss incurred by another party (the ''indemnitee'') due to the relevant acts of the indemnitor or any other party. The duty to indemnify is usually, but not always, coextensive with the contractual duty to "hold harmless" or "save harmless". In contrast, a "guarantee" is an obligation of one party (the ''guarantor'') to another party to perform the promise of a relevant other party if that other party defaults. Indemnities form the basis of many insurance contracts; for example, a car owner may purchase different kinds of insurance as an indemnity for various kinds of loss arising from operation of the car, such as damage to the car itself, or medical expenses following an accident. In an agency context, a principal may be obligated to indemnify their agent for liabilities incurred while carrying out responsibilities under the relationship. While the events giving ris ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
