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In the United States, a health maintenance organization (HMO) is a medical insurance group that provides health services for a fixed annual fee. It is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals, and other entities, acting as a liaison with health care providers on a prepaid basis. The US Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options if the employer offers traditional healthcare options. Unlike traditional indemnity insurance, an HMO covers care rendered by those doctors and other professionals who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers. HMOs cover emergency care regardless of the health care provider's contracted status.
Aetna Inc. is an American managed health care company that sells traditional and consumer directed health care insurance and related services, such as medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans, primarily through employer-paid insurance and benefit programs, and through Medicare. Since November 28, 2018, the company has been a subsidiary of CVS Health.
The Health Insurance Portability and Accountability Act of 1996 is a United States Act of Congress enacted by the 104th United States Congress and signed into law by President Bill Clinton on August 21, 1996. It aimed to alter the transfer of healthcare information, stipulated the guidelines by which personally identifiable information maintained by the healthcare and healthcare insurance industries should be protected from fraud and theft, and addressed some limitations on healthcare insurance coverage. It generally prohibits healthcare providers and businesses called covered entities from disclosing protected information to anyone other than a patient and the patient's authorized representatives without their consent. The bill does not restrict patients from receiving information about themselves. Furthermore, it does not prohibit patients from voluntarily sharing their health information however they choose, nor does it require confidentiality where a patient discloses medical information to family members, friends or other individuals not employees of a covered entity.
The Cigna Group is an American multinational managed healthcare and insurance company based in Bloomfield, Connecticut. Its insurance subsidiaries are major providers of medical, dental, disability, life and accident insurance and related products and services, the majority of which are offered through employers and other groups. Cigna is incorporated in Delaware.
Humana Inc. is a for-profit American health insurance company based in Louisville, Kentucky. In 2023, the company ranked 42 on the Fortune 500 list, which made it the highest ranked company based in Kentucky. It is the fourth largest health insurance provider in the U.S.
Medical billing is a payment practice within the United States healthcare system. The process involves the systematic submission and processing of healthcare claims for reimbursement. Once the services are provided, the healthcare provider creates a detailed record of the patient's visit, including the diagnoses, procedures performed, and any medications prescribed. This information is translated into standardized codes using the appropriate coding system, such as ICD-10-CM or Current Procedural Terminology codes—this part of the process is known as medical coding. These coded records are submitted by medical billing to the health insurance company or the payer, along with the patient's demographic and insurance information. Most insurance companies use a similar process, whether they are private companies or government sponsored programs. The insurance company reviews the claim, verifying the medical necessity and coverage eligibility based on the patient's insurance plan. If the claim is approved, the insurance company processes the payment, either directly to the healthcare provider or as a reimbursement to the patient. The healthcare provider may need to following up on and appealing claims.
The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care. It has become the predominant system of delivering and receiving American health care since its implementation in the early 1980s, and has been largely unaffected by the Affordable Care Act of 2010.
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organizations.
Wolters Kluwer N.V. is a Dutch information services company. The company serves legal, business, tax, accounting, finance, audit, risk, compliance, and healthcare markets.
UnitedHealth Group Incorporated is an American multinational health insurance and services company based in Minnetonka, Minnesota. Selling insurance products under UnitedHealthcare, and health care services under the Optum brand, it is the world's eleventh-largest company by revenue and the largest health care company by revenue.
Express Scripts Holding Company is a pharmacy benefit management (PBM) organization. In 2017 it was the 22nd-largest company in the United States by total revenue as well as the largest pharmacy benefit management (PBM) organization in the United States. Express Scripts had 2016 revenues of $100.752 billion. Since December 20, 2018, the company has been a direct subsidiary of Bloomfield, Connecticut-based Cigna.
Assurant, Inc. is a global provider of risk management products and services with headquarters in Atlanta. Its businesses provide a diverse set of specialty, niche-market insurance products in the property, casualty, extended device protection, and preneed insurance sectors. The company's main operating segments are Global Housing and Global Lifestyle.
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 medical appropriateness before it is provided, by using evidence-based criteria or guidelines.
In the United States, a pharmacy benefit manager (PBM) is a third-party administrator of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program, and state government employee plans. PBMs operate inside of integrated healthcare systems, as part of retail pharmacies, and as part of insurance companies.
Centene Corporation is a publicly traded managed care company based in St. Louis, Missouri, which is an intermediary for government-sponsored and privately insured healthcare programs. Centene ranked No. 25 on the 2023 Fortune 500.
CVS Health Corporation is an American healthcare company that owns CVS Pharmacy, a retail pharmacy chain; CVS Caremark, a pharmacy benefits manager; and Aetna, a health insurance provider, among many other brands. The company is the world's second largest healthcare company, behind UnitedHealth Group. In 2023, the company was ranked 64th in the Forbes Global 2000.
Healthcare rationing in the United States exists in various forms. Access to private health insurance is rationed on price and ability to pay. Those unable to afford a health insurance policy are unable to acquire a private plan except by employer-provided and other job-attached coverage, and insurance companies sometimes pre-screen applicants for pre-existing medical conditions. Applicants with such conditions may be declined cover or pay higher premiums and/or have extra conditions imposed such as a waiting period.
Medidata Solutions is an American technology company that develops and markets software as a service (SaaS) for clinical trials. These include protocol development, clinical site collaboration and management; randomization and trial supply management; capturing patient data through web forms, mobile health (mHealth) devices, laboratory reports, and imaging systems; quality monitor management; safety event capture; and monitoring and business analytics. Headquartered in New York City, Medidata has locations in China, Japan, Singapore, South Korea, the United Kingdom, and the United States.
Elevance Health, Inc. is an American health insurance provider. Prior to June 2022, Elevance Health was named Anthem, Inc. The company's services include medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans through affiliated companies such as Anthem Blue Cross and Blue Shield, Anthem Blue Cross in California, Wellpoint, and Carelon. It is the largest for-profit managed health care company in the Blue Cross Blue Shield Association. As of 2022, the company had 46.8 million members within its affiliated companies' health plans.
Specialty drugs or specialty pharmaceuticals are a recent designation of pharmaceuticals classified as high-cost, high complexity and/or high touch. Specialty drugs are often biologics—"drugs derived from living cells" that are injectable or infused. They are used to treat complex or rare chronic conditions such as cancer, rheumatoid arthritis, hemophilia, H.I.V. psoriasis, inflammatory bowel disease and hepatitis C. In 1990 there were 10 specialty drugs on the market, around five years later nearly 30, by 2008 200, and by 2015 300.
Optum, Inc. is an American healthcare company that provides technology services, pharmacy care services and various direct healthcare services.
References
- 1 2 3 Miller, T. Christian; Rucker, Patrick; Armstrong, David (October 23, 2024). "Inside the Company Helping America's Biggest Health Insurers Deny Coverage for Treatments". ProPublica.
- ↑ O'Donnell, Carl (2017-05-04). "Exclusive: Health benefits manager eviCore explores sale, IPO - sources". Reuters.
- ↑ "EviCore Healthcare Health". The Wall Street Journal. 2016-02-27.
- ↑ Bomey, Nathan. "Express Scripts buys medical benefits management firm eviCore for $3.6 billion". USA TODAY.