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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. [1] This bill is called a claim. [2]
Adjudication is a relatively new process introduced by the government of Victoria, Australia, to allow for the rapid determination of progress claims under building contracts or sub-contracts and contracts for the supply of goods or services in the building industry. This process was designed to ensure cash flow to businesses in the building ...
An explanation of benefits (commonly referred to as an EOB form) is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf. [1] The EOB is commonly attached to a check or statement of electronic payment. An EOB typically describes:
Holden Karau founded a startup to help automate the process of appealing a health insurance claim denial after growing frustrated with the system. She's worked at nearly every FAANG company.
Change Healthcare is a key player in the U.S. healthcare system that depends heavily on insurance, processing about 50% of medical claims for around 900,000 physicians, 33,000 pharmacies, 5,500 ...
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 Affordable Care Act has had huge ramifications on self-funded health plans; market reforms have invalidated many plan designs that were previously used, and now that employees are required to have health insurance and many employers are required to offer health benefits as well, [3] the self-funded industry has enlarged.
Third-party administrators are prominent players in the health care industry and have the expertise and capability to administer all or a portion of the claims process. They are normally contracted by a health insurer or self-insuring companies to administer services, including claims administration, premium collection, enrollment and other ...