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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 ...
The separation between authorization bills and appropriations bills dates back to colonial legislatures and even the British Parliament. [8] At first, this was an informal separation. In the 1830s, however, in reaction to a sharp increase in the number of riders added to appropriations measures, the House and then the Senate added formal rules ...
The House and Senate now consider appropriations bills simultaneously, although originally the House went first. The House Committee on Appropriations usually reports the appropriations bills in May and June and the Senate in June. Any differences between appropriations bills passed by the House and the Senate are resolved in the fall. [11]
Also known as entitlement spending, in US fiscal policy, mandatory spending is government spending on certain programs that are required by law. [1] Congress established mandatory programs under authorization laws. Congress legislates spending for mandatory programs outside of the annual appropriations bill process. Congress can only reduce the ...
In practice, the separation between policy making and funding and the division between appropriations and authorization activities are imperfect. Authorizations for many programs have long lapsed, yet still receive appropriated amounts, while other programs that are authorized receive no funds at all.
Prior authorization, or preauthorization, [1] is a utilization management process used by some health insurance companies in the United States to determine if they will cover a prescribed procedure, service, or medication.
PPO. The Preferred Provider Organization plan is the most popular for those with employment-based insurance (currently 47% of them, in fact). PPOs allow the most flexibility in that people can ...
In insurance, the insurance policy is a contract (generally a standard form contract) between the insurer and the policyholder, which determines the claims which the insurer is legally required to pay. In exchange for an initial payment, known as the premium, the insurer promises to pay for loss caused by perils covered under the policy language.