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All-payer rate setting is a price setting mechanism in which all third parties pay the same price for services at a given hospital. [1] It can be used to increase the market power of payers (such as private and/or public insurance companies) versus providers, such as hospital systems , in order to control costs.
The generic model used in the United States is the chronic care model, which holds that health care does not only involve change in the patient and that high-quality disease care counts the community, the health system, self-management support, delivery system design, decision support, and clinical information systems as important elements in ...
In July 2009, a Special Commission on the Health Care Payment System in Massachusetts distinguished between episode-based payments (i.e., bundled payments) and "global payments" that were defined as "fixed-dollar payments for the care that patients may receive in a given time period... plac[ing] providers at financial risk for both the ...
Payors evaluate claims by verifying the patient's insurance details, medical necessity of the recommended medical management plan, and adherence to insurance policy guidelines. [4] The payor returns the claim back to the medical biller and the biller evaluates how much of the bill the patient owes, after insurance is taken out.
HCUP Logo. The Healthcare Cost and Utilization Project (HCUP, pronounced "H-Cup") is a family of healthcare databases and related software tools and products from the United States that is developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ).
This graph contrasts total health care spending with public spending, in US dollars adjusted for purchasing power parity in Switzerland.. Two-tier healthcare is a situation in which a basic government-provided healthcare system provides basic care, and a secondary tier of care exists for those who can pay for additional, better quality or faster access.
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Primary Care Case Management (PCCM) is a system of managed care in the US used by state Medicaid agencies, in which a primary care provider is responsible for approving and monitoring the care of enrolled Medicaid beneficiaries, typically for a small monthly case management fee in addition to fee-for-service reimbursement for treatment. [1]