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Medical billing, a payment process in the United States healthcare system, is the process of reviewing a patient's medical records and using information about their diagnoses and procedures to determine which services are billable and to whom they are billed.
Insurers are required to implement an appeals process for coverage determination and claims on all new plans. [37] Insurers must spend at least 80–85% of premium dollars on health costs; rebates must be issued if this is violated. [46] [47]
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 ...
The earliest form of HMOs can be seen in a number of "prepaid health plans". In 1910, the Western Clinic in Tacoma, Washington offered lumber mill owners and their employees certain medical services from its providers for a premium of $0.50 per member per month. This is considered by some to be the first example of an HMO.
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Some 31 million Americans have Medicare Advantage plans. But because they routinely deny coverage for necessary care, they threaten rural hospitals, say some CEOS.
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 ...
About 97% of dental benefits in the United States is provided through separate policies from carriers—both stand-alone and medical affiliates—that specialize in this coverage. Typically, these dental plans offer comprehensive preventive benefits. However, major dental expenses, such as crowns and root canals, are just partially covered.