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Medicare Medical Management Tools

Policy

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Published on Jan 23, 2023

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Medical Management

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Overview

To improve consumers’ experience with their coverage and care, health insurance providers in the commercial market work with doctors, nurses, and patients to find ways to make care more efficient, effective, and affordable. Medical management helps deliver on that promise. Examples of medical management tools include: evidencebased medical necessity/medical appropriateness reviews; tiered formulary and provider network designs; prior authorization and concurrent review; step therapy; and quantity and dosing limits. These tools are increasingly being relied upon by government-sponsored health care programs like Medicare.