American Journal of Health Economics
By Tara Templin
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Health Plans' Coverage Determinations for Technology-based Interventions: The Case of Electrical Bone Growth Stimulation
A Huang, M Gemperli, Linda A. Bergthold, Sara J. Singer, Alan M. Garber
The American Journal of Managed Care , 2004
OBJECTIVES: To determine (1) whether commercial health plans' coverage criteria for a costly technology-based medical intervention are consistent with recent clinical effectiveness evidence, (2) whether medical directors adhere to planwide coverage criteria when making coverage determinations for individual patients, and (3) if any organizational characteristics are associated with having more stringent coverage criteria or making more frequent coverage denials.
STUDY DESIGN: Case-based survey of medical directors of US commercial health plans.
Sara J. Singer, A Huang, W Sage, R Osterhoff, Linda A. Bergthold
AcademyHealth , 2003
Linda A Bergthold, Sara J Singer
Academy Health , 2003
Sara J Singer, Linda A. Bergthold
Health Affairs , 2001
With the backlash against managed care, medical necessity has become the focus of increasing controversy. California's health care marketplace has provided some unique opportunities to understand the role of medical necessity in managed care decisionmaking, as the legislature and stakeholders have discovered how little consensus there is on itsmeaning, ownership, and application. Nevertheless , many decisionmakers agree that medical necessity decisions generally involve authorizing treatment for an individual patient.
Linda A Bergthold, S Koebler, Sara J Singer
California Management Review , 2000
Sara J. Singer, Linda A. Bergthold, C Vorhaus, S Olson, I Mutchnick, YY Goh, S Zimmerman, Alain C. Enthoven
California Health Care Foundation , 1999
Medical Necessity was not a problematic issue when remote third party payers rarely challenged physicians' decisions and reimbursed physicians for whatever procedures they chose to order and perform. Over the past several decades, the term medical necessity has served as an innocuous placeholder, enabling insurance plans and physicians to make judgments about coverage that were usually unchallenged.