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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. 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 ...

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

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

    For premium support please call: 800-290-4726 more ways to reach us

  5. Affordable Care Act - Wikipedia

    en.wikipedia.org/wiki/Affordable_Care_Act

    The individual mandate [48] required everyone to have insurance or pay a penalty. The mandate and limits on open enrollment [49] [50] were designed to avoid the insurance death spiral, minimize the free rider problem and prevent the healthcare system from succumbing to adverse selection.

  6. 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 ...

  7. 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 ...

  8. Stormont Vail sues health insurance company Humana alleging ...

    www.aol.com/stormont-vail-sues-health-insurance...

    Stormont Vail Health is suing Humana, alleging that the insurance company owes the Topeka hospital more than $850,000 in underpayments. The alleged underpayments stem from a contractual Medicare ...

  9. 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 ...