Health insurance and managed care : what they are and how they work

Cover
Health Insurance and Managed Care: What They Are and How They Work
Copyright
Contents
Preface
New to This Edition
Acknowledgments
About the Author
Contributors
Keeping Current
Attribution Note
Prologue: Moral Hazard
Chapter 1 A History of Managed Health Care and Health Insurance in the United States
	Learning Objectives
	Introduction
	The 19th Century
	1910 to the Mid-1940s: The Early Years
	The Mid-1940s to the Mid-1960s: The Expansion of Health Benefits
	The Mid-1960s to the Mid-1970s: The Onset of Healthcare Cost Inflation
	The Mid-1970s to the Mid-1980s: The Rise of Managed Care
	The Mid-1980s to the Late 1990s: Growth and Consolidation
	The Managed Care Backlash of the Late 1990s
	2000–2012: HMOs and POS Plans Decline in Enrollment, Costs Grow, and Coverage Erodes
	2012: The Patient Protection and Affordable Care Act
	The Healthcare Market Never Stops Changing
	Conclusion
	Notes
Chapter 2 Health Benefits Coverage and Types of Health Plans and Payers
	Learning Objectives
	Introduction
	Health Benefits Coverage
	Sources of Benefits Coverage and Risk
	Types of Payers
	Conclusion
Chapter 3 The Provider Network
	Learning Objectives
	Introduction
	Contracts and Contracting
	Service Areas, Access Standards, and Network Adequacy
	Physicians and Other Professionals
	Credentialing
	Types of Physician Contracting Situations
	Hospitals and Ambulatory Facilities
	Physician Self-Referral
	Integrated Delivery Systems
	Vertical Integration
	Ancillary Services
	Network Maintenance
	Conclusion
Chapter 4 Provider Payment
	Learning Objectives
	Introduction
	It’s Not Reimbursement. It’s Payment
	Cost Sharing
	Standardized Code Sets
	Risk-Based Versus Non-Risk-Based Payment
	Value-Based Payment
	Physician Payment
	Facility Payment
	Combined Payment of Hospitals and Physicians
	Payment for Ancillary Services
	Payment for Prescription Drugs
	Conclusion
Chapter 5 Utilization Management, Quality Management, and Accreditation
	Learning Objectives
	Introduction
	Prevention and Wellness
	Measuring Utilization
	Medical Necessity and Benefits Coverage Determinations
	Basic Utilization Management
	Appeals of Coverage Denials
	Disease Management, Case Management, Transition Management, and Patient-Centered Medical Home
	Utilization Management of Ancillary Services
	Management of the Pharmaceutical Benefit
	Quality Management
	Health Plan Accreditation, Certification, and Recognition Programs
	Conclusion
Chapter 6 Sales, Governance, and Administration
	Learning Objectives
	Introduction
	Governance and Management
	Information Technology
	Administrative Simplification Under the Health Insurance Portability and Accountability Act
	Analytics and Informatics
	Marketing and Sales of Commercial Products and Services
	Actuarial Services, Underwriting, and Premium Rate Development
	Eligibility
	Enrollment and Billing
	Claims and Benefits Administration
	Fraud, Waste, and Abuse
	Member Services
	Financial Management
	Operational Challenges in the Payer Industry
	Conclusion
Chapter 7 Medicare Advantage and Medicaid Managed Care
	Learning Objectives
	Introduction
	Medicare
	Medicaid
	Conclusion
Chapter 8 Laws and Regulations in Health Insurance and Managed Care
	Learning Objectives
	Introduction
	MCO Structure and Organization
	State Oversight and Regulation
	Conflicts, Preemption, and the Role of the Courts
	Role of Nongovernmental Organizations
	Conclusion
Glossary of Terms and Acronyms
Index