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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 ...
Members in an Aetna preferred provider organization (PPO) and Managed Choice (MC) plan and who receive care from Brown & Toland primary care doctors became part of this program on January 1, 2013.
After a request comes in from a qualified provider, the request will go through the prior authorization process. The process to obtain prior authorization varies from insurer to insurer but typically involves the completion and faxing of a prior authorization form; according to a 2018 report, 88% are either partially or entirely manual.
Aetna, et al., a frustration succinctly summarized in his quote from a previous decision in "Andrews-Clarke v. Travelers Ins. Co.," (a Complaint by a widow for the death of her husband as a consequence of a Managed Care Utilization review decision that cut short her husband's physician's recommended in-hospital treatment plan) as follows:
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The American Association of Physician Specialists (AAPS) is the smallest of three multi-specialty physician/surgeon certifying entities in the United States, providing board certification to both M.D. and D.O. physicians. The AAPS has grouped its certification activities within a single subdivision called the American Board of Physician ...
Considering a recent meta-analysis that shows a decline in physician performance associated with the time elapsed since the physician's initial training, [11] it is essential for physicians to participate in programs such as Maintenance of Certification in order to keep current with medicine's expanding knowledge base and technical advances ...
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