Essentials of managed health care.

Bibliographic Level Mode of Issuance: Monograph.

Machine generated contents note: pt. I Introduction to Health Insurance and Managed Health Care -- 1.A History of Managed Health Care and Health Insurance in the United States / Peter R. Kongstvedt -- Introduction -- 1910 to the Mid-1940s: The Early Years -- The Mid-1940s to Mid-1960s: The Expansion of Health Benefits -- The Mid-1960s to the Mid-1970s: The Onset of Health Care Cost Inflation -- The Mid-1970s to Mid-1980s: The Rise of Managed Care -- The Mid-1980s to 2000: Growth, Consolidation, Maturation, and Backlash -- 2000 to 2010: Costs Rise and Coverage Declines -- Conclusion -- 2.Types of Health Insurers, Managed Health Care Organizations, and Integrated Health Care Delivery Systems / Peter R. Kongstvedt -- Introduction -- Taxonomy -- Insured versus Self-Funded Benefits Plans -- The Managed Care Continuum -- Types of Health Insurers and Managed Care Organizations -- Integrated Health Care Delivery Systems -- Organizations Emerging Under Health Reform

Note continued: Vertical Integration -- Conclusion -- 3.Elements of the Management and Governance Structure / Peter R. Kongstvedt -- Introduction -- Board of Directors -- Key Management Positions -- Medical Management Committees -- Conclusion -- pt. II Network Contracting and Provider Payment -- 4.The Provider Network / Peter R. Kongstvedt -- Introduction -- Why Contract? -- The Service Area -- The National Provider Identifier -- Contract Management -- Physicians and Other Professionals -- The Data Bank -- On-Site Office Evaluation -- Medical Record Review -- Hospitals and Ambulatory Facilities -- Ancillary Services -- Conclusion -- 5.Provider Payment / Peter R. Kongstvedt -- Introduction -- It Is Payment, Not Reimbursement -- The Impact of Payment Methodologies -- Heterogeneity Is the Norm -- Payment of Physicians -- Payment of Hospitals, Health Systems, and Ambulatory Facilities -- Payment for Ambulatory Facility Services

Note continued: Combined Payment of Hospitals and Physicians -- Pay for Performance -- Payment for Ancillary Services -- Other New Models of Payment Under the Patient Protection and Affordable Care Act -- Conclusion -- Appendix 5-1 Examples of Research on the Impact of Managed Care or Capitation on Quality or Outcomes -- 6.Legal Issues in Provider Contracting / Kelli D. Back -- Introduction -- General Issues in Contracting -- Contract Structure -- Common Clauses, Provisions, and Key Factors -- Provider Obligations -- Payment -- Hold Harmless and No Balance Billing Clauses -- Relationship of the Parties -- Use of Name and Proprietary Information -- Notification -- Insurance and Indemnification -- Term, Suspension, and Termination -- "Flow Down" Clauses and Provider Subcontracts -- Declarations -- Closing -- Conclusion -- Appendices -- Appendix 6-1 Sample Physician Agreement -- Appendix 6-2 Attachment B Compensation Schedule

Note continued: Appendix 6-3 Attachment B (Alternate) Capitation Payment -- Appendix 6-4 Sample Hospital Agreement -- Appendix 6-5 Sample Business Associate Addendum -- pt. III Management of Utilization and Quality -- 7.Basic Utilization and Case Management / Peter R. Kongstvedt -- Introduction -- Measurements and Metrics in Utilization Management -- Regional Variations in Utilization and Costs -- Benefits Design and Medical Utilization -- Demand Management -- Categories of Utilization Management -- Determination of Coverage, Medical Necessity, and Evidence-Based Clinical Guidelines -- Authorization and Precertification -- Managing Utilization of Physician Services -- Managing Utilization of Facility-Based Services -- Management of Complex Chronic Conditions -- Retrospective Review -- Routine Ancillary Services -- The Potential Impact of the ACA on Utilization Management -- Conclusion -- 8.Fundamentals and Core Competencies of Disease Management / David W. Plocher

Note continued: Introduction -- Chronic Conditions -- Definition of Disease Management -- Disease Management Companies -- Components Common to Most Programs -- Measuring Effectiveness -- Challenges Using Current Engagement Model -- Health Plan Decision to Build versus Buy -- Outsourcing Contract Financial Risks -- Links to Other Health Care Programs -- International Disease Management -- Potential Future Applications of Disease Management -- Conclusion -- 9.Physician Practice Behavior and Managed Health Care / Peter R. Kongstvedt -- Introduction -- General Aspects of Physician Practice Behavior -- How Physicians Are Responding to these Factors -- What We Should Do Instead: Several Principles -- Tools for Changing Physician Behavior -- Financial Incentives -- Programmatic Approaches to Changing Physician Behavior -- Addressing Noncompliance by Individual Physicians -- Conclusion -- 10.Data Analysis and Provider Profiling in Health Plans / Nancy Garrett -- Introduction

Note continued: Data Sources -- Validity and Reliability -- Use of Claims Data for Analysis and Reporting -- The Need to Adjust for Risk -- Patient Data Confidentiality -- Employer Reporting and Analysis -- Provider Profiling -- Desired Characteristics of Provider Profiles -- Location of Profiling Activity -- Impact of ICD-10 -- Conclusion -- 11.Prescription Drug Benefits in Managed Care / Rusty Hailey -- Introduction -- Prescription Drug Cost and Utilization Trends -- Future Trends Affecting Pharmacy Program Management -- Business Relationships and the Flow of Money -- Pharmacy Benefit Managers -- Prescription Drug Program Management Components -- Pharmacy Benefit Design -- Evidence of Coverage -- Health Information Systems and Claims Processing -- Electronic Prescribing -- Pharmacy Distribution Network -- Developing an Outpatient Pharmacy Provider Network -- Pharmacy Provider Contracts and Claims Adjudication -- Pharmaceutical Contracting

Note continued: Drug Formulary Management -- Mail Service Pharmacy -- Specialty Pharmacy Distribution -- Clinical Pharmacy Programs -- Medicare and Medicaid Pharmacy Benefits -- Measuring Financial Performance -- Pharmacy Benefit Quality Measures and Patient Satisfaction -- Pharmacogenomics -- Conclusion -- 12.Introduction to Managed Behavioral Health Care Organizations / Fred Waxenberg -- Introduction: The Nature and Uniqueness of Behavioral Health -- Legislation Affecting Management of Behavioral Health Care -- The Public Sector -- Networks -- Payment Mechanisms -- New Types of Service Delivery Systems -- Behavioral Health Care Professional Providers -- Types of Services Delivered by Behavioral Networks -- Networks in the Public Sector -- Quality Management of Networks -- Use of Standardized Assessment Tools -- Utilization Management -- Outpatient Management -- Management of Inpatient and Intermediate Levels of Care -- Recent Trends in Utilization Management

Note continued: Recovery and Resiliency -- Specialized Services -- Telemental Health Services -- Intensive Care Management -- Quality of Care -- Accreditation -- In-House versus Outsourced Management of Behavioral Health Services -- Conclusion -- 13.Disease Prevention in Managed Health Care Plans / Marc Manely -- Introduction -- The Case for Prevention: A Cost-Effective Solution for Saving Lives -- A Complete Prevention Program -- Member Benefits -- Services for Members -- Contracting with Health Care Providers -- Public Policies -- Prevention and Health Care Reform -- Conclusion -- 14.Quality Management in Managed Health Care / Pamela B. Siren -- Introduction -- Foundations of Reform: Premise for Quality Management -- Historical Perspective: The Evolution -- Traditional Quality Assurance -- Building on Tradition: Additional Components -- Continuous Improvement Process Model -- Value-Based Purchasing -- Conclusion

Note continued: 15.Accreditation and Performance Measurement Programs in Managed Health Care / Margaret E. O'Kane -- Introduction -- Oversight by Type of Organization -- National Committee for Quality Assurance -- URAC -- Accreditation Association for Ambulatory Health Care -- Conclusion -- pt. IV Sales, Finance, and Administration -- 16.Marketing and Sales / Richard Birhanzel -- Introduction -- Defining the Managed Health Care Marketplace -- Health Plan Marketing Fundamentals -- Challenges to Effective Health Plan Marketing -- High Performance in Health Plan Marketing Practices -- Benefits Design -- Sales -- Conclusion -- 17.Enrollment and Billing / Peter R. Kongstvedt -- Introduction -- The Commercial Market Sector -- Medicare -- Medicaid -- Conclusion -- 18.Claims and Benefits Administration / Elizabeth A. Pascuzzi -- Introduction -- Evolution of the Modern Claims Capability -- 21st-Century Developments -- Defining the Modern Claims Capability

Note continued: Managing the Claims Capability -- Inventory Control -- Core Claims Capability Business Steps -- Coordination of Benefits and Other Party Liability -- Reports -- Cost Containment -- Fraud and Abuse -- Quality Assessments -- Appeals -- Information Technology -- Outsourcing -- 15 Risk Areas and 50 Tips -- Conclusion -- 19.Health Care Fraud and Abuse / Christie A. Moon -- Introduction: The History of Health Care Fraud -- Definitions of Fraud and Abuse -- The Fraud Triangle -- Challenges in Fraud Detection and Prevention -- The Federal Government's Efforts to Crack Down on Health Care Fraud -- Payer and Managed Care Fraud Control Efforts -- Emerging Technology Solutions -- Investigation or Accusation of Health Plan Fraud -- Conclusion -- 20.Member Services / Peter R. Kongstvedt -- Introduction -- The Member Service Environment -- Customer Interaction Support Activities -- Contact Types: Why Members Contact Their Plan -- Member Complaints and Grievances

Note continued: Appeals of Denial of Benefits Coverage or Coverage Rescission -- Resolving the Consumer's Issue -- "Concierge" Approach to Member Services -- Member Satisfaction Surveys and Data -- Proactive Member Services -- Conclusion -- 21.Operational Finance and Budgeting / Christopher R. Campbell -- Introduction -- Regulatory Background -- Components of the Financial Operating Statement -- Balance Sheet -- Regulatory Requirements and Reporting -- Budgeting and Financial Forecasting -- Conclusion -- 22.Underwriting and Rating / Troy M. Filipek -- Introduction -- Underwriting -- Rating -- The Impact of the ACA on Underwriting and Rating -- Conclusion -- 23.Information Systems and Electronic Data Interchange in Managed Health Care / James S. Slubowski -- Introduction -- Foundational Information Systems -- Transforming the Value of the MCO -- Information Security -- Conclusion -- pt. V Special Markets -- 24.Health Plans and Medicare / Amy Huang -- Introduction

Note continued: Background -- Types of Medicare Advantage Plans -- Medicare Advantage Benefits -- Medicare Advantage Payment -- TEFRA and MMA -- Application and Contracting Process -- Enrollment of Medicare Beneficiaries into MA Plans -- Marketing and Sales Rules -- Consumer Protections -- Provider Protections and Rights -- Quality and Plan Performance -- Subregulatory Guidance -- Conclusion -- 25.Medicaid Managed Health Care / Elizabeth Cabot Nash -- Introduction -- Legislative History of Medicaid -- Barriers That Can Affect Access to Care -- Federal Waiver Authority -- Cost Trends -- Complex Populations: Long-Term Care, Behavioral Care, and Special Populations -- Medicaid and the ACA -- Emerging Trends in Medicaid Managed Care -- Conclusion -- 26.The Military Managed Care Health System / Bernie J. Kerr, Jr. -- Introduction -- Brief History of the Military Health System -- The TRICARE Program -- Monitoring MHS Performance -- Current and Future Challenges

Note continued: Conclusion -- Acknowledgments -- Disclosure -- 27.Managed Care in a Global Context / Hugh R. Waters -- Introduction -- A Quick Around-the-World Review of Health Care -- Managed Care as a Tool for Development -- Managed Care within Developed Health Care Systems -- The Experience of U.S. Managed Care Abroad -- Managed Care Readiness and Orientation -- Conclusion -- pt. VI Laws and Regulations -- 28.State Regulation of Managed Health Care / Tom Wilder -- Introduction -- Legislative History -- Regulatory Structure -- Licensing and Corporate Structure -- Consumer Protections -- Provider Contracting -- Insurance Market Rules -- Solvency -- Oversight and Regulation -- Conclusion -- 29.Federal Regulation of Health Insurance and Managed Health Care / Tom Wilder -- Introduction -- History of Federal Regulation -- ERISA -- COBRA -- HIPAA -- Mental Health Parity -- Federal Tax Code -- Federal Regulatory Oversight -- Interaction of State and Federal Requirements

Note continued: Conclusion -- 30.The Patient Protection and Affordable Care Act / Tom Wilder -- Introduction -- Legislative History -- Immediate Reforms -- 2014 Reforms -- Administrative Simplification -- Revenue and Tax Provisions -- Legal and Political Challenges -- Conclusion.

English.