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Linda A. Bergthold
Journal Articles

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.

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Working Papers

Regulating Medical Necessity Decision Making by Managed Care Plans

Sara J. Singer, A Huang, W Sage, R Osterhoff, Linda A. Bergthold
AcademyHealth , 2003
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Journal Articles

Prospects for Improved Decision Making about Medical Necessity

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.

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Journal Articles

In Loco Parentis: The Purchaser Role in Managed Care

Linda A Bergthold, S Koebler, Sara J Singer
California Management Review , 2000
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Working Papers

Decreasing Variation in Medical Necessity Decision Making

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.

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