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It is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals, and other entities, acting as a liaison with health care providers (hospitals, doctors, etc.) on a prepaid basis.
Operation Gatekeeper was a measure implemented during the presidency of Bill Clinton by the United States Border Patrol (then a part of the Immigration and Naturalization Service (INS)), aimed at halting illegal immigration to the United States at the United States–Mexico border near San Diego, California. [1]
The Case Management process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of Case Management include the achievement of optimal health, access to care and appropriate utilization of resources, balanced with the patient's right to self determination.
Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines.
Medical case management is a collaborative process that facilitates recommended treatment plans to assure the appropriate medical care is provided to disabled, ill or injured individuals. It is a role frequently overseen by patient advocates .
Medical Practice Consultants or Healthcare Management Consultants typically advise licensed healthcare providers and health-systems on business and administrative issues. [ 1 ] [ 2 ] These topics commonly include governance, operations, human resources , finance, billing , coding, transactions and marketing.
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 ...
Access to care and Rationing are important dimensions of Health Policy and Management (HPAM) because they address the market force that impacts how and when people get health care services. Rationing in health care occurs due to scarcity; everyone cannot have access to every service and treatment because it would not be an efficient use of ...