Managed Care for Rehab Providers Made Easy: Mastering Contracts and Obtaining Fair Reimbursment / Edition 1

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As the volume of patients who have insurance through managed care networks grows, so does the stress for rehab managers. Spending countless hours negotiating rates, tracking managed care patients, and reading through complicated contract details? Be careful-overlooking any aspect of your managed care contracts could cost your facility thousands of dollars, especially if leads your facility to treat patients at lower reimbursement rates than it deserves. No longer will you sign a contract and cross your fingers! Written by experienced rehab managed care professional, Nancy J. Beckley, MS, MBA, Managed Care for Rehab Providers Made Easy provides expert guidance on assessing how a facility's managed care contracts perform. This book and CD-ROM will also help rehab facilities deal with the challenges managed care networks present, including
• working out contract specifics
• negotiating better rates
• assessing risks
• evaluating contract performance
• credentialing Covering all aspects of managed care to help you plan a strategy that is specific to your market, Managed Care for Rehab Providers Made Easy will walk you through the process of creating new managed care contracts, altering current contracts, and eliminating contracts that are not financially sound for the facility. You'll also benefit from dozens of relevant, time-saving forms, statistics, and other useful tools on the bonus CD-ROM.

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Product Details

  • ISBN-13: 9781601460417
  • Publisher: HcPro, Inc.
  • Publication date: 7/1/2007
  • Edition number: 1
  • Pages: 151
  • Product dimensions: 7.00 (w) x 8.90 (h) x 0.40 (d)

Table of Contents

A word from the author     vi
Introduction     1
Positioning to contract     4
Analyze current networks     5
Network matrix     10
Referral analysis matrix     13
Competitor's analysis     14
Let's get started     17
Insurance-where it all begins     23
Why manage costs?     24
How did we get here?     25
Insurance and managed care products     30
Medicare managed care     34
Medicaid managed care     36
Workers' compensation managed care     37
The contract     39
Managed care contracts for hospitals     40
Managed care contracts for physicians     41
Managed care contracts for ancillary providers and facilities     42
Legal contract review     43
Duties of the parties     47
Credentialing     49
Utilization review and utilization management     50
Medical records     54
Regulatory requirements     54
Governing authority and dispute resolution     55
Term and termination     55
Notices     56
Miscellaneous     56
Review and approval     58
PPO contracts     58
The silent PPO     59
Hospital contracts     63
What's next?     67
Provider applications     69
Facility application     75
Facility site inspection     76
Credentialing of therapists     77
Challenges and opportunities     80
Rates, risk, & financial analysis     81
Rate setting: Actuarial science     82
Values of copays and deductibles     84
Why managed care organizations want providers at risk     86
Why providers want to assume risk     87
Looking at costs     88
Financial indicators for private practice     88
Rate for physical therapy and rehab reimbursement     94
Capitation     97
Risk protections     100
Types of risk to control     100
Limiting and minimizing risk     102
Other factors and considerations in accepting risk     102
Determining cost objectives     103
Managing the copay, or finding dollars     104
Due diligence & negotiation     105
Negotiation      115
Negotiating tips     116
Assignment and challenges     119
Quality assurance & utilization review     121
Assignment and challenge #1     122
Assignment and challenge #2     126
Quality assurance for rehab providers     126
Contract performance analysis     131
Summary     141
Glossary of managed care terminology     143
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