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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.
State availability: all 50 states Plans available: HMO, PPO, PFFS, SNP CMS star rating: 4 stars The Medicare Advantage plans from Humana include HMOs, PFFS, PPOs, and SNPs, depending on your location.
In the 21st century, commercial payers were increasingly using litigation against providers to combat alleged fraud or abuse. [25] 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]
PPO. The Preferred Provider Organization plan is the most popular for those with employment-based insurance (currently 47% of them, in fact). PPOs allow the most flexibility in that people can ...
There are five types of Medicare Advantage plans to choose from:. Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Private Fee-for-Service (PFFS) plan. Special Needs ...
Electronic referrals can result in considerable benefits for service providers. Firstly at the patient level, e-referrals ensure significant improvements to follow-up care coordination [4] by the creation of accurate and timely referrals. Medical decisions are enhanced as each provider involved has the full patient information available to them ...
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 ...
Provider revenues are fixed, and each enrolled patient makes a claim against the full resources of the provider. In exchange for the fixed payment, physicians essentially become the enrolled clients' insurers, who resolve their patients' claims at the point of care and assume the responsibility for their unknown future health care costs.