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  2. Medical billing - Wikipedia

    en.wikipedia.org/wiki/Medical_billing

    Payors evaluate claims by verifying the patient's insurance details, medical necessity of the recommended medical management plan, and adherence to insurance policy guidelines. [4] The payor returns the claim back to the medical biller and the biller evaluates how much of the bill the patient owes, after insurance is taken out.

  3. Humana Named Top Payer in athenahealth PayerView Rankings - AOL

    www.aol.com/news/2013-06-26-humana-named-top...

    Humana Named Top Payer in athenahealth PayerView Rankings Number one ranking highlights Humana's continuing success in providing industry-leading service to healthcare providers LOUISVILLE, Ky ...

  4. National Provider Identifier - Wikipedia

    en.wikipedia.org/wiki/National_Provider_Identifier

    A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS). The NPI has replaced the Unique Physician Identification Number (UPIN) as the required identifier for Medicare services, and is used by other payers ...

  5. Utilization management - Wikipedia

    en.wikipedia.org/wiki/Utilization_management

    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 [1] Committee on Utilization Management by Third Parties (1989; IOM is now the National ...

  6. 'Deny, deny, deny': By rejecting claims, Medicare Advantage ...

    www.aol.com/news/deny-deny-deny-repeatedly...

    A Humana spokesman provided this statement: “In our Medicare Advantage hospital contracts, Humana pays rates, on average, that are above fee-for-service Medicare rates.

  7. Capitation (healthcare) - Wikipedia

    en.wikipedia.org/wiki/Capitation_(healthcare)

    Physicians and other health care providers lack the necessary actuarial, underwriting, accounting and finance skills for insurance risk management, but their most severe problem is the greater variation in their estimates of the average patient cost, which leaves them at a financial disadvantage as compared to insurers whose estimates are far ...

  8. Whistleblower Lawsuit Against Humana: Settles Medicare ... - AOL

    www.aol.com/whistleblower-lawsuit-against-humana...

    Last week, Humana Inc (NYSE:HUM) agreed to pay $90 million to the federal government to settle a whistleblower lawsuit alleging fraudulent Medicare Part D bids. The lawsuit, filed by Phillips ...

  9. Prior authorization - Wikipedia

    en.wikipedia.org/wiki/Prior_authorization

    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. [ 2 ] [ 3 ] A failed authorization can result in a requested service being denied or in an insurance company requiring the patient to go through a ...