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Managing Managed Care in the Medical Practice / Edition 2

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Overview

Understand, assess and evaluate managed care arrangements offered in today's marketplace. Practical tips on the pros and cons of participation, analyzing a managed care contract, plus capitation ethical issues.

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Editorial Reviews

Doody's Review Service
Reviewer: Fang Sun, PhD (California State University Dominguez Hills)
Description: This is the second edition of an overview of today's concept of managed care as it relates to the business aspects of medical practice. The first edition was published in 1996.
Purpose: Due to the dynamics of managed care since 1996, such an objective is certainly worthy to pursue. The authors have done a wonderful job to meet the objective.
Audience: The book is intended for the people who manage or simply are interested in managed care in medical practices. With years of experience in the field, the authors are truly credible authorities in the subject matter of the book.
Features: The book reviews the fundamentals and concepts, and terminology and definitions of managed care. It provides practical strategies to manage managed care in medical practices and useful tools on assessing plans and reviewing contracts.
Assessment: This is a good resource for understanding various aspects of, and managing, managed care in medical practices. It is worthy reading by all who care about how to maintain the fiscal health of their medical practices in the environment of managed care.

3 Stars from Doody
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Product Details

  • ISBN-13: 9781579472931
  • Publisher: AMA Press
  • Publication date: 2/1/2004
  • Series: Practice Success Ser.
  • Edition number: 2
  • Pages: 158
  • Product dimensions: 8.50 (w) x 11.00 (h) x 0.40 (d)

Table of Contents

1 Managed Care Today 1
Perspectives of Managed Care 1
Management Styles for Each Perspective 3
The Current Environment for Practices 5
2 Developing a Managed Care Strategy 15
Specific Identification of the Contracting Parties 15
Specifying the Rates and Products 17
Maintaining an Exit Strategy 17
Avoiding All-Products Provisions 19
Avoiding "At the Payer's Discretion" Clauses 20
Maintaining Complete Files 22
Forming a Contract Negotiation Team 22
Negotiation Planning 25
ABCs of Language Review 33
Timeliness of Payments 36
Legal Rights and Boundaries 37
3 Providing Cost-effective Health Care 39
Maximum Throughput 39
Cost per RVU Calculation 41
Using Cost per RVU to Budget 43
4 Billing for Medical Services in a Managed Care Environment 51
Managing Managed Care Contracts 52
The Claims Process 52
Policies and Procedures and Their Documentation 73
5 Medicare and Medicaid and Managed Care 77
Medicare Managed Care 77
Medicaid Managed Care 86
6 Risk Contracting 91
Risk Readiness 92
Contracting 95
Implementation 100
7 Ethical Considerations in Managed Care 103
The Patient-Physician Relationship 103
Conflicts Between Patient and Physician 104
Patient Autonomy and Responsibility 105
Guidelines From the Council on Ethical and Judicial Affairs 105
8 HIPAA and Compliance 109
Legislative History 109
Privacy Rule Overview 111
Strategic Approach to HIPAA Compliance 113
Who Must Comply 114
Personnel Designations: Privacy Officer and Contact Person 116
Policies and Procedures 118
Permitted Uses and Disclosures 119
Authorizations for Nonpermitted Uses and Disclosures 121
Minimum Necessary Rule 122
Acknowledgment of Privacy Practices 124
Individual Rights 126
Training 128
Business Associates 128
State Law Preemption 131
App. A Prompt-Pay Statutes and Regulations 135
App. B AMA Model Managed Care Contract, Third Edition 139
Glossary 141
Index 155
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