Cost Containment and Utilization Management

What this video covers

• How a health maintenance organization (HMO) referral requirement commonly differs from a preferred provider organization (PPO) that typically allows direct specialist booking
• Why preauthorization is approval for a named service under listed conditions, not a guarantee of claim payment
• How a formulary, drug tier, and cost sharing differ from a provider network
• When preauthorization, concurrent review, and retrospective review happen, and what each evaluates
• How to calculate an eligible expense using approved visits and allowed charges, then apply any deductible or coinsurance
• How to count additional approved days after the original concurrent review period ends
• How case management differs from disease management, and why care program enrollment does not bypass policy claim rules