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Major insurers selling Medicare Part C plans include Aetna, Blue Cross Blue Shield, Cigna, Humana, Kaiser Permanente and UnitedHealthcare. ... But you won’t need a referral to see a specialist.
Aetna Inc. (/ ˈ ɛ t n ə / ET-nə) is an American managed health care company that sells traditional and consumer directed health care insurance and related services, such as medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans, primarily through employer-paid (fully or partly) insurance and benefit programs, and through Medicare.
If a patient wishes to see a specialist or is counseled to see a specialist, a referral can be made by a GP. Canadians do wait for some treatments and diagnostic services. The median wait time for diagnostic services such as MRI and CAT scans [ note 1 ] is two weeks, with 86.4% waiting less than three months. [ 19 ]
Examples included litigation between Aetna and a group of surgical centers over an out-of-network overbilling scheme and kickbacks for referrals, where Aetna was ultimately awarded $37 million. [25] While Aetna has led the initiative, other health insurance companies have engaged in similar efforts. [26]
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 member(s) are not required to use a gatekeeper or obtain a referral before seeing a specialist. In that case, the traditional benefits are applicable. If the member uses a gatekeeper, the HMO benefits are applied. However, the beneficiary cost sharing (e.g., co-payment or coinsurance) may be higher for specialist care. [3]
Ideally, the primary care physician acts on behalf of the patient to collaborate with referral specialists, coordinate the care given by varied organizations such as hospitals or rehabilitation clinics, act as a comprehensive repository for the patient's records, and provide long-term management of chronic conditions.
The German healthcare system had introduced copayments in the late 1990s in an attempt to prevent overutilization and control costs. For example, Techniker Krankenkasse-insured members above 18 years pay the copayments costs for some medicines, therapeutic measures and appliances such as physiotherapy and hearing aids up to the limit of 2% of the family's annual gross income.