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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 ...
[51] [52] It was reported, that Molina Healthcare operated plans that denied medical care under requests for prior authorization of services in more than 25% of cases in 2019. About 2.7 million people were enrolled in these plans at the time, while another 8.4 million people were enrolled in plans with denial rates higher than average at 15-25%.
Molina Healthcare, a major Medicaid provider, said that it was considering exiting some markets in 2018, citing "too many unknowns with the marketplace program." Molina lost $110 million in 2016 due to having to contribute $325 million more than expected to the ACA "risk transfer" fund that compensated insurers with unprofitable risk pools.
The earliest form of HMOs can be seen in a number of "prepaid health plans". In 1910, the Western Clinic in Tacoma, Washington offered lumber mill owners and their employees certain medical services from its providers for a premium of $0.50 per member per month.
In 2022, 295 plans (up from 256 in 2021) covered all Medicare services, plus Medicaid-covered behavioral health treatment or long term services and support. [6] In 2022, 1000 MA plans were projected to enroll 3.7 million people in VBID. The hospice benefit will be offered by 115 Medicare Advantage plans in 22 states and territories. [6]
Prior to his leadership roles at the firm, Molina held a number of other key roles at Molina Healthcare. These included: Medical Director (supervising medical and risk management matters) and vice president (in charge of provider contracting, member services, marketing and QA).
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