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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] The payor returns the claim back to the medical biller and the biller evaluates how much of the bill the patient owes, after insurance is taken out.
In the United States, a third-party administrator (TPA) is an organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity. [1] It is also a term used to define organizations within the insurance industry which administer other services such as underwriting and customer service.
In the United States, a pharmacy benefit manager (PBM) is a third-party administrator of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program, and state government employee plans.
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 ...
Self-funded health care, also known as Administrative Services Only (ASO), is a self insurance arrangement in the United States whereby an employer provides health or disability benefits to employees using the company's own funds. [1]
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Unwarranted variations in medical practice refer to the differences in care that cannot be explained by the illness/medical need or by patient preferences. The term “unwarranted variations” was first coined by Dr. John Wennberg when he observed small area (geographic) and practice style variations, which were not based on clinical rationale. [5]
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