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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.
Aging populations, a changing disease spectrum, and the progress and change in technology of health care become the major problems which lead to increasing of health care costs. [4] Then, how to use drug utilization evaluation and drug economy evaluation to improve and optimize the allocation of medical and health resources is a major problem ...
Clinical peer review, also known as medical peer review is the process by which health care professionals, including those in nursing and pharmacy, evaluate each other's clinical performance. [ 1 ] [ 2 ] A discipline-specific process may be referenced accordingly (e.g., physician peer review , nursing peer review ).
Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...
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 ...
Health experts said it may not be enough to weed out the worst providers and persuade violators to reform. “If a compliance system doesn’t have any teeth it will be ignored,” said Josh Perry, an Indiana University professor who has written extensively about the hospice industry.
WASHINGTON (Reuters) -The Justice Department late on Wednesday asked a U.S. appeals court to reject an emergency bid by TikTok to temporarily block a law that would require its Chinese parent ...
The Institute for Clinical and Economic Review provides independent evaluation of the clinical effectiveness and comparative value of health care interventions, while also overseeing the New England Comparative Effectiveness Public Advisory Council (CEPAC), an independent body of physicians and patient representatives that aids patients ...