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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.
The Affordable Care Act (ACA) established the health insurance rate review program in order to protect consumers from unreasonable rate increases. [1] Through this program, proposed premium increases in the small group and individual markets that are above a threshold amount (ten percent or more, as of February 2014) are reviewed by states or ...
Clinical peer review. Clinical peer review, also known as medical peer review is the process by which health care professionals, including those in nursing and pharmacy, evaluate each other's clinical performance. [1] [2] A discipline-specific process may be referenced accordingly (e.g., physician peer review, nursing peer review ).
Software development. Code review (sometimes referred to as peer review) is a software quality assurance activity in which one or more people check a program, mainly by viewing and reading parts of its source code, either after implementation or as an interruption of implementation. At least one of the persons must not have authored the code.
Health technology assessment ( HTA) is a multidisciplinary process that uses systematic and explicit methods to evaluate the properties and effects of a health technology. [1] Health technology is conceived as any intervention ( test, device, medicine, vaccine, procedure, program) at any point in its lifecycle ( pre-market, regulatory approval ...
The Healthcare Effectiveness Data and Information Set ( HEDIS) is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS was designed to allow consumers to compare health plan performance to other plans and to national or regional benchmarks.
Health Insurance Portability and Accountability Act of 1996; Other short titles: Kassebaum–Kennedy Act, Kennedy–Kassebaum Act: Long title: An Act To amend the Internal Revenue Code of 1986 to improve portability and continuity of health insurance coverage in the group and individual markets, to combat waste, fraud, and abuse in health insurance and health care delivery, to promote the use ...
No. 20-219, 596 U.S. ___ (2022) The Affordable Care Act ( ACA ), formally known as the Patient Protection and Affordable Care Act ( PPACA) and colloquially 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.