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Independent Medical Review
An independent medical review (IMR) is the process where physicians review medical cases in order to provide claims determinations for health insurance payers, workers compensation insurance payers or disability insurance payers. Peer review also is used in order to define the review of sentinel events in a hospital environment for quality management purposes such as to look at bad outcomes and determine whether there was any mis-diagnosis, mistreatment or any systemic problems involved which led to the sentinel event. Physicians who perform independent medical reviews must be board certified and in active practice in that same area of treatment. These physicians are contracted by an independent review organization, medical management companies, third party administrators (TPAs) or utilization review companies to provide objective, unbiased determinations on what the root cause of the treatment was, whether there is medical necessity, if there was a sentinel event, what was the r ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Independent Review Organization
Independent or Independents may refer to: Arts, entertainment, and media Artist groups * Independents (artist group), a group of modernist painters based in the New Hope, Pennsylvania, area of the United States during the early 1930s * Independents (Oporto artist group), a Portuguese artist group historically linked to abstract art and to Fernando Lanhas, the central figure of Portuguese abstractionism Music Groups, labels, and genres * Independent music, a number of genres associated with independent labels * Independent record label, a record label not associated with a major label * Independent Albums, American albums chart Albums * ''Independent'' (Ai album), 2012 * ''Independent'' (Faze album), 2006 * ''Independent'' (Sacred Reich album), 1993 Songs * "Independent" (song), a 2007 song by Webbie * "Independent", a 2002 song by Ayumi Hamasaki from '' H'' News and media organizations * '' The Independent'', a British online newspaper. * '' The Malta Independent'', a Malt ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Third Party Administrator
In the United States, a third-party administrator (TPA) is an organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity. It is also a term used to define organizations within the insurance industry which administer other services such as underwriting and customer service. This can be viewed as outsourcing the administration of the claims processing, since the TPA is performing a task traditionally handled by the company providing the insurance or the company itself. Often, in the case of insurance claims, a TPA handles the claims processing for an employer that self-insures its employees. Thus, the employer is acting as an insurance company and underwrites the risk. The risk of loss remains with the employer, and not with the TPA. An insurance company may also use a TPA to manage its claims processing, provider networks, utilization review, or membership functions. While some third-party administrators may operate as units of ins ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Medical Necessity
Medical necessity is a legal doctrine in the United States related to activities that may be justified as reasonable, necessary, and/or appropriate based on evidence-based clinical standards of care. In contrast, unnecessary health care lacks such justification. Other countries may have medical doctrines or legal rules covering broadly similar grounds. The term clinical medical necessity is also used. Implementations of doctrine Medicare Medicare pays for medical items and services that are "reasonable and necessary" or "appropriate" for a variety of purposes. By statute, Medicare may pay only for items and services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member" unless there is another statutory authorization for payment. Medicare has a number of policies that describe coverage criteria, including National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Employee Retirement Income Security Act Of 1974
The Employee Retirement Income Security Act of 1974 (ERISA) (, codified in part at ) is a U.S. federal tax and labor law that establishes minimum standards for pension plans in private industry. It contains rules on the federal income tax effects of transactions associated with employee benefit plans. ERISA was enacted to protect the interests of employee benefit plan participants and their beneficiaries by: * Requiring the disclosure of financial and other information concerning the plan to beneficiaries; * Establishing standards of conduct for plan fiduciaries; * Providing for appropriate remedies and access to the federal courts. ERISA is sometimes used to refer to the full body of laws that regulate employee benefit plans, which are mainly in the Internal Revenue Code and ERISA itself. Responsibility for interpretation and enforcement of ERISA is divided among the Department of Labor, the Department of the Treasury (particularly the Internal Revenue Service), and the P ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Patient Protection And Affordable Care Act
The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act and colloquially known as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act of 2010 amendment, it represents the U.S. healthcare system's most significant regulatory overhaul and expansion of coverage since the enactment of Medicare and Medicaid in 1965. The ACA's major provisions came into force in 2014. By 2016, the uninsured share of the population had roughly halved, with estimates ranging from 20 to 24 million additional people covered. The law also enacted a host of delivery system reforms intended to constrain healthcare costs and improve quality. After it went into effect, increases in overall healthcare spending slowed, including premiums for employer-based insurance plans. The increased coverage was due ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Case Management (US Health System)
Case management is a managed care technique within the health insurance, health care coverage system of the United States. It involves an integrated system that manages the delivery of comprehensive healthcare services for enrolled patients. Case managers are employed in almost every aspect of health care and these employ different approaches in the control of clinical actions. Definition The American Case Management Association (ACMA), a Nonprofit organization, non-profit association dedicated to the support and development of the profession of case management through educational forums, networking opportunities, legislative advocacy and establishing the industry's Standards of Practice, defines case management as: Case management focuses on delivering personalized services to patients to improve their care, and involves four steps: # Referral (medicine), Referral of new patients (perhaps from another service if the client has relocated to a new area out of previous jurisdict ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Utilization Management
Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers, particularly health insurance companies, to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. Critics have argued that if cost cutting by insurers is the focus of their use of UM criteria, it could lead to healthcare rationing by overzealous denial of care as well as retrospective denial of payment, delays in care, or unexpected financial risks to patients. Aspects 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 (IOM) Committee on Utilization Management by Third Parties (1989; IOM is now the National Acad ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
URAC
Headquarters and Offices The URAC offices are located in Washington, DC at 1220 L Street, NW. URAC is in the heart of the city, close to the White House, the Capitol and congressional offices and major transportation hubs. About half of URAC staff members work from the Washington, DC office and half work from home offices around the United States. Accreditation Programs and Application Process URAC’s accreditation programs include specialty pharmacy, digital health, utilization management, health plan, case management and many others across the health care spectrum. URAC’s accreditation programs require organizations to demonstrate how they meet standards set by experts in health care in the areas of patient management, pharmacy product handling, patient communications, credentialing of providers, review timelines, and patient safety and security. In order to earn an accreditation, organizations must submit a variety of policies and procedures which are reviewed by a URAC a ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
