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Physicians bill their services using procedure codes developed by a seventeen-member committee known as the CPT Editorial Panel. The AMA nominates eleven of the members while the remaining seats are nominated by the Blue Cross and Blue Shield Association, the Health Insurance Association of America, CMS, and the American Hospital Association ...
A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS). The NPI has replaced the Unique Physician Identification Number (UPIN) as the required identifier for Medicare services, and is used by other payers ...
In the health insurance and the health care industries, FFS occurs if doctors and other health care providers receive a fee for each service such as an office visit, test, procedure, or other health care service. [5] Payments are issued only after the services are provided. FFS is potentially inflationary by raising health care costs. [6]
Health care providers often receive payments for their services rendered from health insurance providers. In the United States, the Department of Health and Human Services defines a health care provider as any "person or organization who furnishes, bills, or is paid for health care in the normal course of business." [1] [2]
[4]: 2 In the period between 1910 and 1940, early healthcare plans formed into two models: a capitated plan (essentially an HMO), and a plan which paid service providers, such as the Blue Cross and Blue Shield Plans. [4]: 2 One of the earliest examples is a 1910 "prepaid group plan" in Tacoma, Washington for lumber mills.
In the United States, an independent practice association (IPA) is an association of independent physicians, or other organizations that contracts with independent care delivery organizations, and provides services to managed care organizations on a negotiated per capita rate, flat retainer fee, or negotiated fee-for-service basis.
For dentists, the American Dental Association defines a usual and customary fee as "the fee an individual dentist most frequently charges for a specific dental procedure independent of any contractual agreement. It is always appropriate to modify the fee based on the nature and severity of the condition being treated and by any medical or ...
In U.S. health insurance, a preferred provider organization (PPO), sometimes referred to as a participating provider organization or preferred provider option, is a managed care organization of medical doctors, hospitals, and other health care providers who have agreed with an insurer or a third-party administrator to provide health care at ...