A Practical Guide to Reimbursement in Managed Care

by JoAnna B. Younts, Steven D. Hamilton, Franklin Stevens, MacKenzie S. Wallace

Overview

This book provides a detailed historical account of Medicare reimbursement and payment approaches used across nearly all provider types, along with a practical discussion of commercial payer contracting and payment strategies. It then concludes with a deep dive into the legal issues that arise in payer-provider disputes, including the most common issues and case examples.

Product Details

ISBN-13:	9781639053810
Publisher:	American Bar Association
Publication date:	01/30/2024
Pages:	202
Product dimensions:	6.00(w) x 9.00(h) x (d)

About the Author

JoAnna has worked in the healthcare industry for nearly 35 years. Her primary area of expertise is Medicare reimbursement and its relationship to commercial reimbursement. She worked as a contractor for the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) on the development of the Medicare Outpatient Prospective Payment System (OPPS) for hospitals as well as evaluations of the Inpatient Prospective Payment System (IPPS).

JoAnna splits her time between strategic advisory work for payers and providers and payer-provider disputes. In her advisory work, she provides analysis and recommendations regarding reimbursement and contracting, including fee schedule updates, benchmarking and out-of-network policies. In litigation, she serves as a consulting expert on issues relating to billing and coding, reimbursement rates, payment policies and out-of-network issues.

Mr. Frank Stevens is a Managing Director in the Health Analytics practice at Berkeley Research Group, LLC (BRG). He is a former Principal in the National Life Sciences, Health Care and Government Industry practice of Deloitte Financial Advisory Services LLP and was the national health plan "heavy sector" partner with over 40 years of experience in health and managed care operations.

Mr. Stevens currently limits his practice to State and Federal regulatory issues, assisting clients with regulatory compliance and serving as an independent monitor of regulatory / legal settlements. 

Mackenzie is an experienced trial attorney representing health care entities, businesses, and directors in high-stakes litigation. Hospitals and health care providers turn to Mackenzie for representation in coverage and reimbursement disputes; fraud, and civil RICO claims; Texas Prompt Pay Act, qui tam, and False Claims Act litigation; and matters relating to the violation of federal and state anti-kickback provisions and Stark laws.