US Healthcare Administration 📞 Book a 1:1

00 Start Here

Glossary & Acronyms Home How to Use This Map The 90-Second Mental Model

01 The Stakeholders

ACA Marketplace Plans Brokers, Consultants & Benefits Advisors Clearinghouses Commercial & Employer-Sponsored Insurance Dual Eligibles & D-SNPs Group Purchasing Organizations (GPOs)🔒 Independent Review Organizations (IROs)Industry Trade Associations & Lobbying Medicaid & Managed Medicaid Medicare Medicare Advantage Members & Patients 🔒 Payers (Health Plans)Physician Groups, IPAs & Medical Groups Post-Acute & Long-Term Care Providers & Health Systems Regulators & Oversight Bodies Self-Funded Plans & ASO Specialty Benefit Managers 🔒 The Member Digital Front Door The Stakeholders 🔒 Third Party Administrators (TPAs)TRICARE & VA Health

02 How Money Flows

Coordination of Benefits & Subrogation Cost Sharing Denials Management & Remittance Codes (CARC, RARC)DRGs & Prospective Payment Systems EDI & X12 Transaction Standards 🔒 Encounter Data Submission (EDPS, RAPS & State Encounters)Fee Schedules & Allowed Amounts How Money Flows Medical Debt & Hospital Collections Medical Loss Ratio (MLR)Price Transparency & Good Faith Estimates Real-Time Eligibility & Benefits Verification Reimbursement Models Revenue Cycle Management (RCM)Risk Adjustment & HCC Coding The Claims Lifecycle The Premium Dollar

03 Coverage & Benefits

Benefit Design & the SBC Coverage & Benefits Eligibility & Enrollment EMTALA & Emergency Care Coverage EPSDT — Medicaid's Child & Adolescent Benefit Essential Health Benefits & State Mandates Experimental & Investigational Coverage Medical Policy & Coverage Determinations Plan Types (HMO, PPO, EPO, POS, HDHP)🔒 Prior Authorization Provider Networks

04 Utilization Management

Appeals & Grievances Behavioral Health Review 🔒 Clinical Criteria (MCG & InterQual)Concurrent Review 🔒 Determination & Notification Letters Diagnostic Imaging & Testing Review Durable Medical Equipment (DME) Review 🔒 Gold-Carding & Auto-Approval 🔒 Information Requests & RFI Templates 🔒 Inpatient Admissions Review 🔒 Inter-Rater Reliability (IRR)Local & National Coverage Determinations (LCD & NCD)🔒 Medical Necessity Member Notices in Utilization Management 🔒 Outpatient & Ambulatory Review 🔒 Peer-to-Peer Review Post-Acute Care Review 🔒 Precertification Lists & CPT Mapping 🔒 Retrospective Utilization Review 🔒 Site-of-Care & Site-of-Service Steering Specialty Drugs & Infusion Review 🔒 The Prior Authorization Workflow 🔒 The Utilization Management Team Turnaround Time & Regulatory Clocks 🔒 UM Operational Metrics, Staffing & Productivity 🔒 Utilization Management 🔒 Utilization Management by Service Line 🔒 Utilization Review

05 Care Management & Population Health

Behavioral Health Management & Parity Care Gaps & SDOH Care Management & Population Health Care Navigation & Advocacy Case Management Disease & Chronic Care Management Maternity Care Management 🔒 Medicaid LTSS & Home- and Community-Based Services Population Health Management Remote Monitoring & Digital Health Programs Telehealth & Virtual Care Transitions of Care & the Readmissions Reduction Program

06 Clinical Data, Coding & Interoperability

Clinical Data, Coding & Interoperability Clinical Documentation Integrity (CDI)EHRs & the Provider Tech Stack Healthcare Cybersecurity & Operational Resilience HL7, FHIR & USCDI Information Blocking & the Cures Act Medical Coding Systems Modifiers & Place-of-Service Coding SMART on FHIR & EHR Apps TEFCA & Health Information Exchange The Da Vinci Project (CRD, DTR, PAS)

07 Payment & Program Integrity

Claims Editing & the NCCI (Correct Coding Edits)DRG Validation & Clinical Validation Fraud, Waste & Abuse (FWA) & the SIU Itemized Bill Review 🔒 OIG Enforcement: Exclusions, CIAs & Civil Monetary Penalties Overpayment Recovery, COB & Subrogation Payment & Program Integrity 🔒 Payment Integrity Pre-Pay vs Post-Pay Review Retrospective Claim Review

08 Pharmacy & PBMs

340B Drug Pricing 🔒 Cell, Gene & One-Time Therapy Financing Formularies, Rebates & the Drug Supply Chain 🔒 GLP-1 & Anti-Obesity Medication Management Medicare Part D Medication Adherence, DUR & Medication Therapy Management Pharmacy & PBMs Pharmacy Benefit Managers (PBMs)Pharmacy Prior Authorization & Step Therapy Specialty Pharmacy

09 Value-Based Care & Risk

Accountable Care Organizations (ACOs)Bundled & Episode-Based Payments 🔒 Capitation, Full-Risk & Delegated Risk Fee-for-Service vs Value-Based Care Quality Measurement (HEDIS, Stars, MIPS)Stop-Loss Insurance & Reinsurance Value-Based Care & Risk

10 Regulation & Policy

42 CFR Part 2 — SUD Record Confidentiality 🔒 Accreditation (NCQA & URAC)CMS (Centers for Medicare & Medicaid Services)🔒 Delegation Oversight & FDR Management ERISA & Self-Funded Plans HIPAA 🔒 Medicare Advantage Oversight, Audits & Marketing Rules Mental Health Parity (MHPAEA)Prior Authorization Data & Public Reporting Regulation & Policy Section 1557, Language Access & Health Equity Stark Law & the Anti-Kickback Statute State Regulation & Departments of Insurance The Affordable Care Act (ACA)The CMS Interoperability & Prior Authorization Final Rule (CMS-0057-F)The Healthcare Compliance Program The No Surprises Act

11 The Vendor Landscape

Care Management Platforms Clinical Criteria & Content Vendors Core Administrative Processing Systems 🔒 Health-IT Investors, Private Equity & Strategic Acquirers Payment Integrity Vendors Prior Authorization Vendors Provider Data & Credentialing Vendors 🔒 System Integrators, Consultancies & Clinical BPOs 🔒 The AI & Automation Entrants The Health-IT Vendor Map The Vendor Landscape 🔒 Utilization Management Platforms 🔒 Value-Based Care Enabler Companies

12 Where It Breaks & Where AI Wins

🔒 AI Governance & Model Risk in Healthcare Administration Building & Selling Healthtech (Go-to-Market)🔒 The Automation Opportunity Map 🔒 The Cost of Administrative Complexity The Founder's Theses 🔒 The Prior Authorization Problem 🔒 The Provider-Payer AI Arms Race 🔒 The Startup Opportunity Index 🔒 What Breaks in Utilization Management Today 🔒 Where It Breaks & Where AI Wins 🔒 Who Has the Right to Win Why Prior Authorization Exists

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The Cost of Administrative Complexity

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Linked from

Building & Selling Healthtech (Go-to-Market)
Care Navigation & Advocacy
Cost Sharing
Denials Management & Remittance Codes (CARC, RARC)
EHRs & the Provider Tech Stack
How Money Flows
Medical Loss Ratio (MLR)
Medical Policy & Coverage Determinations
Members & Patients
Precertification Lists & CPT Mapping
Providers & Health Systems
Retrospective Claim Review
Revenue Cycle Management (RCM)
Specialty Benefit Managers
System Integrators, Consultancies & Clinical BPOs
The 90-Second Mental Model
The AI & Automation Entrants
The Affordable Care Act (ACA)
The Automation Opportunity Map
The Da Vinci Project (CRD, DTR, PAS)
The Founder's Theses
The No Surprises Act
The Prior Authorization Problem
The Provider-Payer AI Arms Race
The Stakeholders
Where It Breaks & Where AI Wins
Why Prior Authorization Exists

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