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Prior Authorization
Prior authorization 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. The process is intended to act as a safety and cost-saving measure although it has received criticism from physicians for being costly and time-consuming. Overview Prior authorization is a check run by some insurance companies or third-party payers in the United States before they will agree to cover certain prescribed medications or medical procedures. There are a number of reasons that insurance providers require prior authorization, including age, medical necessity, the availability of a generic alternative, or checking for drug interactions. A failed authorization can result in a requested service being denied or in an insurance company requiring the patient to go through a separate process known as "step therapy" or "fail first." Step therapy dictates that a patient must first see ... [...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] |
Health Insurance
Health insurance or medical insurance (also known as medical aid in South Africa) is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among many individuals. By estimating the overall risk of health risk and health system expenses over the risk pool, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to provide the money to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization, such as a government agency, private business, or not-for-profit entity. According to the Health Insurance Association of America, health insurance is defined as "coverage that provides for the payments of benefits as a result of sickness or injury. It includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment". Background A health i ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
United States
The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territories, nine Minor Outlying Islands, and 326 Indian reservations. The United States is also in free association with three Pacific Island sovereign states: the Federated States of Micronesia, the Marshall Islands, and the Republic of Palau. It is the world's third-largest country by both land and total area. It shares land borders with Canada to its north and with Mexico to its south and has maritime borders with the Bahamas, Cuba, Russia, and other nations. With a population of over 333 million, it is the most populous country in the Americas and the third most populous in the world. The national capital of the United States is Washington, D.C. and its most populous city and principal financial center is New York City. Paleo-Americ ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Health Insurance In The United States
Health insurance in the United States is any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance, or a social welfare program funded by the government. Synonyms for this usage include "health coverage", "health care coverage", and "health benefits". In a more technical sense, the term "health insurance" is used to describe any form of insurance providing protection against the costs of medical services. This usage includes both private insurance programs and social insurance programs such as Medicare, which pools resources and spreads the financial risk associated with major medical expenses across the entire population to protect everyone, as well as social welfare programs like Medicaid and the Children's Health Insurance Program, which both provide assistance to people who cannot afford health coverage. In addition to medical expense insurance, "health insurance" may also refer to insurance covering disability or l ... [...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] |
Generic Drug
A generic drug is a pharmaceutical drug that contains the same chemical substance as a drug that was originally protected by chemical patents. Generic drugs are allowed for sale after the patents on the original drugs expire. Because the active chemical substance is the same, the medical profile of generics is equivalent in performance. A generic drug has the same active pharmaceutical ingredient (API) as the original, but it may differ in some characteristics such as the manufacturing process, formulation, excipients, color, taste, and packaging. Although they may not be associated with a particular company, generic drugs are usually subject to government regulations in the countries in which they are dispensed. They are labeled with the name of the manufacturer and a generic non-proprietary name such as the United States Adopted Name (USAN) or International Nonproprietary Name (INN) of the drug. A generic drug must contain the same active ingredients as the original brand-name ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Drug Interaction
Drug interactions occur when a drug's mechanism of action is disturbed by the concomitant administration of substances such as foods, beverages, or other drugs. The cause is often the inhibition of the specific receptors available to the drug, forcing the drug molecules to bind to other non-intended targets which results in an array of side-effects. The term selectivity describes a drug’s ability to target a single receptor, rendering a predictable physiological response. For example, the binding of acetylcholine to muscarinic tracheal smooth-muscle receptors (M3) results in smooth muscle contractions. When free receptors become occupied by agonists - drugs that bind and activate receptors - and antagonists - drugs that inhibit/ block activation - the opportunity for drugs to target their intended receptor decreases as most receptors are already occupied. Therefore, when the number of free receptors decreases, the drugs begin binding to other secondary receptors, causing s ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Step Therapy
Step therapy, also called step protocol or a fail first requirement, is a managed care approach to prescription. It is a type of prior authorization requirement that is intended to control the costs and risks posed by prescription drugs. The practice begins medication for a medical condition with the most cost-effective drug therapy and progresses to other more costly or risky therapies only if necessary. The increase in prescription drug prices in the United States has increased the pressure on health care providers to keep down the cost of prescription medication while maintaining high levels of availability to the patient. The use of generic drugs whenever possible allows health care plans to pursue both goals effectively. Physicians and managed care providers may disagree on the proper step therapy, and patients are encouraged to become knowledgeable in managing their own care. Opponents Opponents of step therapy, such as Fail First Hurts, have detailed the pitfalls of step ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Journal Of The American Board Of Family Medicine
The ''Journal of the American Board of Family Medicine'' is the official publication of the American Board of Family Medicine. It was formerly published as ''The Journal of the American Board of Family Practice'' by the Board of the Massachusetts Medical Society The Massachusetts Medical Society (MMS) is the oldest continuously operating state medical association in the United States. Incorporated on November 1, 1781, by an act of the Massachusetts General Court, the MMS is a non-profit organization th .... Publications established in 1988 Family medicine journals Bimonthly journals English-language journals Academic journals published by learned and professional societies of the United States {{med-journal-stub ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
American Medical Association
The American Medical Association (AMA) is a professional association and lobbying group of physicians and medical students. Founded in 1847, it is headquartered in Chicago, Illinois. Membership was approximately 240,000 in 2016. The AMA's stated mission is "to promote the art and science of medicine and the betterment of public health." The Association also publishes the ''Journal of the American Medical Association'' (JAMA). The AMA also publishes a list of Physician Specialty Codes which are the standard method in the U.S. for identifying physician and practice specialties. The American Medical Association is governed by a House of Delegates as well as a board of trustees in addition to executive management. The organization maintains the AMA Code of Medical Ethics, and the AMA Physician Masterfile containing data on United States Physicians. The ''Current Procedural Terminology'' coding system was first published in 1966 and is maintained by the Association. It has also publi ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Maryland State Legislature
The Maryland General Assembly is the state legislature of the U.S. state of Maryland that convenes within the State House in Annapolis. It is a bicameral body: the upper chamber, the Maryland Senate, has 47 representatives and the lower chamber, the Maryland House of Delegates, has 141 representatives. Members of both houses serve four-year terms. Each house elects its own officers, judges the qualifications and election of its own members, establishes rules for the conduct of its business, and may punish or expel its own members. The General Assembly meets each year for 90 days to act on more than 2,300 bills including the state's annual budget, which it must pass before adjourning ''sine die''. The General Assembly's 441st session convened on January 9, 2020. History The forerunner of the Maryland General Assembly was the colonial institution, an Assembly of Free Marylanders (and also Council of Maryland). Maryland's foundational charter created a state ruled by the ''Palati ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Arizona House Of Representatives
The Arizona State House of Representatives is the lower house of the Arizona Legislature, the state legislature of the U.S. state of Arizona. The upper house is the Senate. The House convenes in the legislative chambers at the Arizona State Capitol in Phoenix. Its members are elected to two-year terms, with a term limit of four consecutive terms (eight years). Each of the state's 30 legislative districts elects two state house representatives and one state senator, with each district having a population of at least 203,000. The last election occurred on November 8, 2022, with the Republican Party currently holding a narrow majority in the House. Leadership of the House The Speaker is elected by the majority party caucus along with the Majority Leader, the Assistant Majority Leader, and the Majority Whip. The House as a whole shall pass a House resolution confirming the Speaker and the Chief Clerk of the House. In addition to presiding over the body, the Speaker is also the ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
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