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Aetna Inc. (/ ˈ ɛ t n ə / ET-nə) is an American managed health care company that sells traditional and consumer directed health care insurance and related services, such as medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans, primarily through employer-paid (fully or partly) insurance and benefit programs, and through Medicare.
The class action lawsuit alleges Aetna Health is claiming reimbursement it isn't entitled to when customers settle medical malpractice cases.
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 ...
Founded in 1948, [26] Arkansas Blue Cross Blue Shield (ABCBS) [27] is an independent licensee of the Blue Cross Blue Shield Association, and the largest healthcare provider in the state. [28] It donated $1.98 million to The Walton College of Business toward founding its Robert L. Shoptaw Master of Healthcare Business Analytics Program. [ 29 ]
Provider revenues are fixed, and each enrolled patient makes a claim against the full resources of the provider. In exchange for the fixed payment, physicians essentially become the enrolled clients' insurers, who resolve their patients' claims at the point of care and assume the responsibility for their unknown future health care costs.
Recent claim experience—whether better or worse than average—is a strong predictor of future costs in the near term. But the average health status of a particular small employer group tends to regress over time towards that of an average group. [91] The process used to price small group coverage changes when a state enacts small group ...