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De Facto Denial
De facto denial or functional denial is a situation that can occur in health insurance and workers' compensation insurance when a claim is not denied outright, but in practical terms it is not covered. If cost reduction by an insurer is the reason for ''de facto'' denials as part of utilization management, it can lead to healthcare rationing through denials of care or coverage, delays in care, and unexpected financial risks to patients. Types There are at least two types of de facto denials, non-response and underpayment / non-payment. De facto denials are separate from formal denials. Non-response denials If an insurer does not respond in a timely manner to a claim or request to authorize a service, it may be challenged in court as a de facto denial of service, though other facts of the case will be relevant. In workers' compensation cases, de facto denial of coverage due to non-response can occur if an insurer fails to respond in writing within a certain time. In the United S ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Health Insurance In The United States
Health insurance in the United States is any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance, or a social welfare program funded by the government. Synonyms for this usage include "health coverage", "health care coverage", and "health benefits". In a more technical sense, the term "health insurance" is used to describe any form of insurance providing protection against the costs of medical services. This usage includes both private insurance programs and social insurance programs such as Medicare, which pools resources and spreads the financial risk associated with major medical expenses across the entire population to protect everyone, as well as social welfare programs like Medicaid and the Children's Health Insurance Program, which both provide assistance to people who cannot afford health coverage. In addition to medical expense insurance, "health insurance" may also refer to insurance covering disability ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Workers' Compensation
Workers' compensation or workers' comp is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment in exchange for mandatory relinquishment of the employee's right to sue his or her employer for the tort of negligence. The trade-off between assured, limited coverage and lack of recourse outside the worker compensation system is known as "the compensation bargain.” One of the problems that the compensation bargain solved is the problem of employers becoming insolvent as a result of high damage awards. The system of collective liability was created to prevent that and thus to ensure security of compensation to the workers. While plans differ among jurisdictions, provision can be made for weekly payments in place of wages (functioning in this case as a form of disability insurance), compensation for economic loss (past and future), reimbursement or payment of medical and like expenses (functioning in this case as a form o ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Medical Billing
Medical billing is a payment practice within the United States healthcare system. The process involves a healthcare provider obtaining insurance information from a patient and filing, following up on and appealing claims with health insurance companies in order to receive payment for services rendered, such as testing, treatments, and procedures. The same process is used for most insurance companies, whether they are private companies or government sponsored programs. Medical coding reports what the diagnosis and treatment were and prices are applied accordingly. Medical billers are encouraged, but not required by law, to become certified by taking an exam such as the CMRS Exam, RHIA Exam, CPB Exam and others. Certification schools are intended to provide a theoretical grounding for students entering the medical billing field. Some community colleges in the United States offer certificates, or even associate degrees, in the field. Those seeking advancement may be cross-trained ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Cost Reduction
Cost reduction is the process used by companies to reduce their costs and increase their profits. Depending on a company’s services or products, the strategies can vary. Every decision in the product development process affects cost: design is typically considered to account for 70–80% of the final cost of a project such as an engineering project or the construction of a building. Companies typically launch a new product without focusing too much on cost. Cost becomes more important when competition increases and price becomes a differentiator in the market. The importance of cost reduction in relation to other strategic business goals is often debated. Cost reduction strategies * Supplier consolidation: see examples in the aerospace manufacturing industry * Component consolidation * Low-cost country sourcing * Request for quotations (RFQ) * Supplier cost breakdown analysis * Function cost analysis / Value analysis / Value engineering * Design for manufacture / Des ... [...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 appropriateness before it is provided 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 (IOM) Committee on Utilization Management by Third Parties (1989; IOM is now the National Ac ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Health Care Rationing
Health care rationing refers to mechanisms that are used for resource allocation ('' viz.'' ration) in health care. Overall health care United States Healthcare rationing in the United States of America is largely accomplished through market forces, though major government programs include Medicare, Medicaid, Veterans Affairs, and the Indian Health Service. Most Americans have private health insurance, and non-emergency health care rationing decisions are made based on what the insurance company or government insurance will pay for, what the patient is willing to pay for (though health care prices are often not transparent), and the ability and willingness of the provider to perform uncompensated care. The Emergency Medical Treatment and Active Labor Act of 1986 requires any properly equipped hospital receiving Medicare funds (nearly all private hospitals) to provide emergency healthcare regardless of citizenship, immigration status, or ability to pay. The government als ... [...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 appropriateness before it is provided 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 (IOM) Committee on Utilization Management by Third Parties (1989; IOM is now the National Ac ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Colorado
Colorado (, other variants) is a state in the Mountain states, Mountain West subregion of the Western United States. It encompasses most of the Southern Rocky Mountains, as well as the northeastern portion of the Colorado Plateau and the western edge of the Great Plains. Colorado is the List of U.S. states and territories by area, eighth most extensive and List of U.S. states and territories by population, 21st most populous U.S. state. The 2020 United States Census, 2020 United States census enumerated the population of Colorado at 5,773,714, an increase of 14.80% since the 2010 United States Census, 2010 United States census. The region has been inhabited by Indigenous peoples of the Americas, Native Americans and their Paleo-Indians, ancestors for at least 13,500 years and possibly much longer. The eastern edge of the Rocky Mountains was a major migration route for early peoples who spread throughout the Americas. "''Colorado''" is the Spanish adjective meaning "ruddy", th ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Independent Medical Review
An independent medical review (IMR) is the process where physicians review medical cases in order to provide claims determinations for health insurance payers, workers compensation insurance payers or disability insurance payers. Peer review also is used in order to define the review of sentinel events in a hospital environment for quality management purposes such as to look at bad outcomes and determine whether there was any mis-diagnosis, mistreatment or any systemic problems involved which led to the sentinel event. Physicians who perform independent medical reviews must be board certified and in active practice in that same area of treatment. These physicians are contracted by an independent review organization, medical management companies, third party administrators (TPAs) or utilization review companies to provide objective, unbiased determinations on what the root cause of the treatment was, whether there is medical necessity, if there was a sentinel event, what was the r ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Prior Authorization
Prior authorization 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. The process is intended to act as a safety and cost-saving measure although it has received criticism from physicians for being costly and time-consuming. Overview Prior authorization 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. There are a number of reasons that insurance providers require prior authorization, including age, medical necessity, the availability of a generic alternative, or checking for drug interactions. A failed authorization can result in a requested service being denied or in an insurance company requiring the patient to go through a separate process known as " step therapy" or "fail first." Step therapy dictates that a patient must first ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Patient Protection And Affordable Care Act
The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act and colloquially known as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act of 2010 amendment, it represents the U.S. healthcare system's most significant regulatory overhaul and expansion of coverage since the enactment of Medicare and Medicaid in 1965. The ACA's major provisions came into force in 2014. By 2016, the uninsured share of the population had roughly halved, with estimates ranging from 20 to 24 million additional people covered. The law also enacted a host of delivery system reforms intended to constrain healthcare costs and improve quality. After it went into effect, increases in overall healthcare spending slowed, including premiums for employer-based insurance plans. The increased coverage was d ... [...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 appropriateness before it is provided 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 (IOM) Committee on Utilization Management by Third Parties (1989; IOM is now the National Ac ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
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