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

Health Insurance and Managed Care: What They Are and How They Work is a concise introduction to the workings of health insurance and managed care within the American health care system. Written in clear and accessible language, this text offers an historical overview of managed care before walking the reader through the organizational structures, concepts, and practices of the health insurance and managed care industry. The Fifth Edition is a thorough update that addresses the current status of The Patient Protection and Affordable Care Act (ACA), including political pressures that have been partially successful in implementing changes. This new edition also explores the changes in provider payment models and medical management methodologies that can affect managed care plans and health insurer. MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict Cover 1 Health Insurance and Managed Care: What They Are and How They Work 2 Copyright 3 Contents 4 Preface 6 New to This Edition 8 Acknowledgments 12 About the Author 14 Contributors 16 Keeping Current 18 Attribution Note 20 Prologue: Moral Hazard 22 Chapter 1 A History of Managed Health Care and Health Insurance in the United States 32 Learning Objectives 32 Introduction 32 The 19th Century 33 1910 to the Mid-1940s: The Early Years 33 The Mid-1940s to the Mid-1960s: The Expansion of Health Benefits 35 The Mid-1960s to the Mid-1970s: The Onset of Healthcare Cost Inflation 36 The Mid-1970s to the Mid-1980s: The Rise of Managed Care 37 The Mid-1980s to the Late 1990s: Growth and Consolidation 41 The Managed Care Backlash of the Late 1990s 46 2000–2012: HMOs and POS Plans Decline in Enrollment, Costs Grow, and Coverage Erodes 49 2012: The Patient Protection and Affordable Care Act 51 The Healthcare Market Never Stops Changing 53 Conclusion 55 Notes 57 Chapter 2 Health Benefits Coverage and Types of Health Plans and Payers 60 Learning Objectives 60 Introduction 60 Health Benefits Coverage 61 Sources of Benefits Coverage and Risk 66 Types of Payers 72 Conclusion 83 Chapter 3 The Provider Network 84 Learning Objectives 84 Introduction 84 Contracts and Contracting 85 Service Areas, Access Standards, and Network Adequacy 88 Physicians and Other Professionals 90 Credentialing 95 Types of Physician Contracting Situations 98 Hospitals and Ambulatory Facilities 101 Physician Self-Referral 105 Integrated Delivery Systems 107 Vertical Integration 112 Ancillary Services 112 Network Maintenance 113 Conclusion 114 Chapter 4 Provider Payment 116 Learning Objectives 116 Introduction 116 It’s Not Reimbursement. It’s Payment 118 Cost Sharing 119 Standardized Code Sets 119 Risk-Based Versus Non-Risk-Based Payment 121 Value-Based Payment 121 Physician Payment 121 Facility Payment 135 Combined Payment of Hospitals and Physicians 143 Payment for Ancillary Services 147 Payment for Prescription Drugs 149 Conclusion 152 Chapter 5 Utilization Management, Quality Management, and Accreditation 154 Learning Objectives 154 Introduction 154 Prevention and Wellness 156 Measuring Utilization 156 Medical Necessity and Benefits Coverage Determinations 158 Basic Utilization Management 160 Appeals of Coverage Denials 165 Disease Management, Case Management, Transition Management, and Patient-Centered Medical Home 165 Utilization Management of Ancillary Services 170 Management of the Pharmaceutical Benefit 173 Quality Management 179 Health Plan Accreditation, Certification, and Recognition Programs 184 Conclusion 188 Chapter 6 Sales, Governance, and Administration 190 Learning Objectives 190 Introduction 190 Governance and Management 192 Information Technology 196 Administrative Simplification Under the Health Insurance Portability and Accountability Act 197 Analytics and Informatics 200 Marketing and Sales of Commercial Products and Services 200 Actuarial Services, Underwriting, and Premium Rate Development 208 Eligibility 212 Enrollment and Billing 214 Claims and Benefits Administration 216 Fraud, Waste, and Abuse 221 Member Services 223 Financial Management 227 Operational Challenges in the Payer Industry 230 Conclusion 235 Chapter 7 Medicare Advantage and Medicaid Managed Care 236 Learning Objectives 236 Introduction 236 Medicare 237 Medicaid 254 Conclusion 261 Chapter 8 Laws and Regulations in Health Insurance and Managed Care 264 Learning Objectives 264 Introduction 264 MCO Structure and Organization 265 State Oversight and Regulation 266 Conflicts, Preemption, and the Role of the Courts 278 Role of Nongovernmental Organizations 279 Conclusion 280 Glossary of Terms and Acronyms 282 Index 340 Health Insurance And Managed Care: What They Are And How They Work Is A Concise Introduction To The Foundations Of The American Managed Health Care System. Written In Clear And Accessible Language, This Handy Guide Offers An Historical Overview Of Managed Care And Then Walks The Reader Through The Organizational Structures, Concepts, And Practices Of The Managed Care Industry. The Fifth Edition Is A Thorough Update That Addresses The Current Status Of The Affordable Care Act Including Political Pressures That Have Been Partially Successful In Implementing Changes. This New Edition Also Explores The Changes In Provider Payment Models And Medical Management Methodologies That Can Affect Managed Care Plans And Health Insurers In Many Ways. The Fifth Edition Also Offers New Or Expanded Coverage Of: The History Of Health Insurance And Managed Care; Instability In The Public Exchange Marketing And Sales Channels; The Impact Of Limitations On Sales, Governance And Administrative (sg&a) Costs And Profits; Continued Changes In Accountable Care Organizations (acos); Continued Changes In Payment Mechanisms Such As Value-based Payment Under The Medicare Improvement For Patients And Providers Act (mippa); Continued Consolidation Of The Health Sector Market Place--,The Term Managed Care Or Managed Healthcare Describes A Group Of Activities Ostensibly Intended To Reduce The Cost Of Providing For-profit Health Care While Improving The Quality Of That Care. One Of The Most Common Forms Of Managed Care Is The Use Of A Panel Or Network Of Healthcare Providers To Provide Care To Enrollees. Managed Care Is So Ubiquitous In The Us, It Has Become Nearly Synonymous With Health Insurance.health Insurance And Managed Care: What They Are And How They Work Is A Concise Introduction To The Foundations Of The American Managed Health Care System. Written In Clear And Accessible Language, This Handy Guide Offers An Historical Overview Of Managed Care And Then Walks The Reader Through The Organizational Structures, Concepts, And Practices Of The Managed Care Industry-- Health Insurance and Managed What They Are and How They Work is a concise introduction to the workings of health insurance and managed care within the American health care system. Written in clear and accessible language, this text offers an historical overview of managed care before walking the reader through the organizational structures, concepts, and practices of the health insurance and managed care industry. The Fifth Edition is a thorough update that addresses the current status of The Patient Protection and Affordable Care Act (ACA), including political pressures that have been partially successful in implementing changes. This new edition also explores the changes in provider payment models and medical management methodologies that can affect managed care plans and health insurer. The Fifth Edition also offers new or expanded coverage Moral hazard, and its application in health insurance and managed care The ever expanding and evolving payment systems and methodologies used in the U.S. Healthcare System The role of benefits design along with discussion about medical necessity and its impact on benefits coverage The impact of limitations on sales, governance and administrative (SG&A) costs and profits Continued changes in payment mechanisms such as value-based payment under the Medicare Improvement for Patients and Providers Act (MIPPA) Medicare Part D, the drug benefit and the plans that offer it, as well as the complexities of Medicare Advantage payment plans, Medicaid expansion under ACA, and more. "Health Insurance and Managed Care: What They Are and How They Work is a concise introduction to the foundations of the American managed health care system. Written in clear and accessible language, this handy guide offers an historical overview of managed care and then walks the reader through the organizational structures, concepts, and practices of the managed care industry. The Fifth Edition is a thorough update that addresses the current status of the Affordable Care Act including political pressures that have been partially successful in implementing changes. This new edition also explores the changes in provider payment models and medical management methodologies that can affect managed care plans and health insurers in many ways. The Fifth Edition also offers new or expanded coverage of: The history of health insurance and managed care; Instability in the public exchange marketing and sales channels; The impact of limitations on sales, governance and administrative (SG&A) costs and profits; Continued changes in Accountable Care Organizations (ACOs); Continued changes in payment mechanisms such as value-based payment under the Medicare Improvement for Patients and Providers Act (MIPPA); Continued consolidation of the health sector market place"-- Provided by publisher "The term "managed care" or "managed healthcare" describes a group of activities ostensibly intended to reduce the cost of providing for-profit health care while improving the quality of that care. One of the most common forms of managed care is the use of a panel or network of healthcare providers to provide care to enrollees. Managed care is so ubiquitous in the US, it has become nearly synonymous with health insurance. Health Insurance and Managed Care: What They Are and How They Work is a concise introduction to the foundations of the American managed health care system. Written in clear and accessible language, this handy guide offers an historical overview of managed care and then walks the reader through the organizational structures, concepts, and practices of the managed care industry"-- Provided by publisher