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  2. Medical billing - Wikipedia

    en.wikipedia.org/wiki/Medical_billing

    A medical biller then takes the coded information, combined with the patient's insurance details, and forms a claim that is submitted to the payors. [ 2 ] 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 ]

  3. Medically Unlikely Edit - Wikipedia

    en.wikipedia.org/wiki/Medically_Unlikely_Edit

    A Medically Unlikely Edit (MUE) is a US Medicare unit of service claim edit applied to Medical claims against a procedure code for medical services rendered by one provider/supplier to one patient on one day. Claim edits compare different values on medical claim to a set of defined criteria to check for irregularities, often in an automated ...

  4. Capitation (healthcare) - Wikipedia

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

    Secondary capitation is a relationship arranged by a managed care organization between a physician and a secondary or specialist provider, such as an X-ray facility or ancillary facility such as a durable medical equipment supplier whose secondary provider is also paid capitation based on that PCP's enrolled membership.

  5. What to do if your health claim has been denied - AOL

    www.aol.com/finance/south-florida-patients...

    UnitedHealthcare released a statement saying the company approves and pays about 90% of medical claims upon submission. They also stated that of those claims that require further review, around 0. ...

  6. Fee-for-service - Wikipedia

    en.wikipedia.org/wiki/Fee-for-service

    Electronic referral, when a specialist evaluates medical data (such as laboratory tests or photos) to diagnose a patient instead of seeing the patient in person, would often improve health care quality and lower costs. However, "in the private fee-for-service context, the loss of specialist income is a powerful barrier to e-referral, a barrier ...

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

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

    The hospital’s staff has to spend time resubmitting claims, she added, saying: “It costs us 2 or 3 times the amount of labor and investment to collect on one claim.”

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  9. Self-funded health care - Wikipedia

    en.wikipedia.org/wiki/Self-funded_health_care

    Self-funding involves a transfer of risk from the employee and his/her dependents to the employer directly. Self-funded health plans pay health claims out of plan assets; there is no element of traditional insurance on these programs, and the employer assumes all additional liability for claims that have not been paid by plan (trust) assets.

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