The Health Care Financing Administration

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“Reimbursement” in healthcare refers to the decision of the entity paying for an item or service (called the “payor”) of whether a particular item or service is covered by a particular healthcare payment program for the patient at issue and therefore eligible for payment. “Payors” refers to the entity through which an individual has healthcare coverage. The federal government is the largest single payor of healthcare services in the United States through a variety of federal healthcare programs such as the Medicare and Medicaid programs established under the Social Security Act (SSA).
The Department of Health and Human Services (HHS) administers Medicare through the Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA). CMS also oversees the Medicaid program in conjunction with the state agency that administers the program within the state. As a result, CMS has a great deal to say about which products are eligible for reimbursement and under what circumstances. Many other federal healthcare programs often follow the direction of the reimbursement decisions that CMS makes. Private insurers also frequently adopt the reimbursement protocols that CMS establishes and follows.
The US system is at its heart an employment-based health insurance system in which employers play a key role as sponsors of their employees. There are over 1200 private insurance companies offering health insurance in the US, which are
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