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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 ...
Prior authorization, or preauthorization, [1] is a utilization management process used by some health insurance companies in the United States to determine if they ...
The largest private U.S. health insurers are Aetna, Blue Cross Blue Shield entities, Cigna Healthcare, Elevance Health (formerly Anthem), Humana Inc. and United Healthcare.
In 2019, MA operators denied 13% of prior authorization requests that would have been accepted under traditional Medicare. [17] In 2019 alone, MA plans cost tax-payers $9 billion more than if those enrollees were in traditional Medicare. [18]
Blue Cross NC, which had been the state’s third-party administrator for the SHP for more than 40 years, in February 2023 filed a complaint with the North Carolina Office of Administrative Hearings.
Aetna will replace Blue Cross Blue Shield of North Carolina as the administrator for the state’s health plan, State Treasurer Dale Folwell announced Wednesday. The health plan, which covers ...
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 ]
After losing to Aetna, Blue Cross Blue Shield NC is calling it quits on its legal fight to retain the contract to administer the state’s health plan. State workers: Your benefits will soon go ...