Managed health care in the new millennium : innovative financial modeling for the 21st century / David I. Samuels
- Machine generated contents note: ch. 1 An Updated Introduction to Managed Care and Capitation -- Introduction -- A Simple Definition---But Not So Simple History---Of Managed Care and Capitation -- Understanding Managed Care in the Private and Public Sectors: A Reality Check -- Understanding Capitation---And Not Just Financially -- Effects of Public Policies on Capitation and Capitated Relationships -- A Simplified Understanding of Managed Care Models -- Two Basic Demand Models of Managed Care: Illness-Based versus Wellness-Based -- Understanding Health Plans -- ch. 2 Understanding Managed Care Industry Operations -- Introduction to the Insurance Industry -- Understanding ERISA Implications for HMOs and Employers -- Responsibility for Negligence under ERISA -- Administration of Practice Management -- Credentialing of Network Providers -- Actions of Employed Staff/Practitioners -- Contractual Liability Issues -- Unreasonable Benefit Determination -- Balance-Billing Violations of FQHMOs -- Introduction to Managed Care Underwriting -- Purchaser Selection -- Benefit Plan Design -- Claims History -- Role of MCO Reinsurance -- Aggregate Reinsurance -- Individual Reinsurance -- Introduction to Commercially Insured Populations -- The "50-50 Rule" -- Control of Commercial Risk Populations -- Understanding Rating Methodologies: Community versus Experience -- Community Ratings -- Basic Community Ratings -- Community Ratings by Class -- Experience Rating Methodologies -- Experience-Based Community Ratings -- Understanding and Predicting Medical Losses -- Introduction to Actuarial Mathematics -- Premium and Product Issues -- Payer Premium Revenues -- Payer Nonoperating Revenue Sources -- Employer Benefit Plan Design -- Cost-Sharing Impacts on Product Design -- Deductible Mechanisms -- Share-of-Cost Payments -- Out-of-Pocket Maximums -- Incentives and Disincentives -- Health Plan Enrollment -- Cost Data to Predict Losses -- Community Utilization and Service Intensities -- Impact of Utilization Management -- Effectiveness of Health Care Management -- Probability Matrix of Predicted Use -- Operational Loss Sources -- MCO Operational Elements to Minimize Losses -- Payer-Provider Risk Relationships -- Stop-Loss and PMPM Relationships -- Underwriting and Reinsurance Relationships -- Other Interrelationships -- Risk Banding and Provider Risk-Sharing Arrangements -- Payer-Provider Financial Relationships -- Cost Sharing -- Reinsurance Recoveries -- COB Relationships -- "Pursue-and-Pay" COB Method -- "Pay-and-Pursue" COB Method -- Capitation Adjustments Based on Percentage of Premium Revenue -- Claims Management and Processing -- Claims Adjudication -- Referral Management -- Provider Authorizations -- Prospective Authorizations -- Concurrent Authorizations -- Retrospective Authorizations -- Pended Authorizations -- Denied Authorizations -- Subordinate ("Sub-") Authorizations -- Payer Development of Provider Panels -- Outcomes Reporting -- Advanced Studies in Capitated Managed Care -- Per Member, per Month -- Full-Risk Capitation -- Global Capitation -- Gatekeeping and Primary Care Capitation -- Contact and Specialty Care Capitation -- Subcapitation Modeling -- Tertiary Capitation -- Nonindexed Capitation -- Understanding of "Operational" Capitation for the Health Care Industry -- Conclusion -- ch. 3 Managed Care Provider and Practitioner Operations -- Introduction -- The Board of Directors -- Board Committees -- MCO Managers -- Chief Executive Officer -- Medical Director -- Network Director -- Chief Financial Officer -- Operations Director -- Marketing Director -- General Counsel/Compliance -- Payer Benefit Determination -- MCO Services -- MCO Economics -- Specialty HMOs -- Federal Qualification Eligibility by Office for Managed Care -- Application Process for FQHMO Qualification -- Site Visit Prior to FQHMO Qualification -- FQHMO Postqualification Process -- MCO Marketing and Product Development -- Market Segmentation Strategies -- Defining Desirable Market Segments -- Strategic Product-Positioning Drivers -- Distribution Channel Drivers of Effective Product Placement -- Revenue Drivers Based on Requests for Proposal and Requests for Information -- Request for Proposal -- Request for Information -- Payer and Practitioner/Provider Services -- Contracting -- Carve-Outs versus Carve-Ins -- Outsourcing -- Strategies to Manage Provider/Practitioner Costs -- Practitioner Profiling -- Episodes-of-Care Profiling -- Incentive Compensation Data -- Payer/Provider Budgeting and Financial/Resource Estimation -- MCO Budgeting -- Analyses of Administrative Costs -- Analyses of Capitated Medical Service Costs -- Analyses of Fee-for-Service Practitioner Costs -- Office Visit Frequency -- Nonnetwork and Referral Services Data -- Hospital Inpatient Utilization/Payment Data -- Comparative Market Data -- Conclusion -- ch. 4 Managed Care Organization Quality Benchmarking -- Introduction -- Accreditation of HMOs under NCQA -- NCQA Accreditation Process -- Areas of NCQA Review -- Clinical Indicators Measured through MCO Accreditation -- Joint Commission Quality Indicators -- Health-Plan Employer Data and Information Set -- URAC Accreditation Procedures -- URAC Accreditation Process -- Areas of URAC Review -- Responsibility -- Information -- Procedures -- Appeals of Denied Authorizations -- Confidentiality -- Staff and Program Requirements -- Accessibility -- Accreditation of Preferred Provider Organizations -- AAPI Review Process -- Areas of AAPI Review -- Introduction to Six Sigma Quality Benchmarking Methodology -- Quality Improvement and Benchmarking Approach for Six Sigma -- Utilizing Six Sigma Benchmarking in MCO Operations -- Learning from Clinicians: Health Care Finance's Best Response to Six Sigma -- Conclusion -- ch. 5 Managing the Managed Care Enrollee -- Introduction -- Managed Care Expectations of Enrollees -- Managed Care Enrollee Access and Accessibility Modeling -- Accessibility to Appropriate Specialty Care -- Provider/Practitioner Autonomy -- Access to Non-Allopaths and Allied Health Professionals -- Managed Care Choice -- Managed Care Quality at the Enrollee Level -- Managed Care Enrollee Impacts on Provider/Practitioner Costs -- Health Guidance Services for Managed Care Enrollees -- Community-Based Health Information -- Payer- or MCO-Provided Consumer Education -- Enrollee Health Guidance Internet Sites -- Enrollee Responsibility to Comply with Strategies for Treatment, Disease Adaptation, Health Status Improvement, and Healthiness Management -- Appropriateness of Provider Resource Utilization of Enrollees -- Methods of Transforming Behavior of Capitated Enrollees -- Lifestyle Improvement Contracts -- Incentivizing Enrollee Compliance -- Establishing Enrollee "Feedback Loops" -- Typical Member Rights and Responsibilities -- MCO Responsibilities for Improper Care -- MCO Contractual Responsibilities to Enrollees -- Conclusion -- ch. 6 Enrollee-Based Financial and Mathematical Prediction Models -- Introduction -- Overview of Case Management/Utilization Management -- Use of Financial Data Derived from CM/UM -- Incurred-but-Not-Reported Case Management Data -- Indicators of Inappropriate IBNR Levels -- Inpatient Services -- Outpatient Services -- Practitioner Services -- Other Medical Services -- Ancillary Services -- Prescription Drugs -- Reinsurance Premiums -- Administrative Expenses -- Managed Care-Specific Financial Indicators -- Payer Indicators -- Practitioner Indicators -- Average Visits PMPY -- Referrals PMPY -- Authorization Compliance -- MCO Internal Control -- Controlling Claims by Linking to Authorizations -- PCP Cooperation in Enhancing Controls -- Conclusion -- ch. 7 Management of Managed Care Information for Modeling Purposes -- Introduction -- Data Elements and Sources -- Data Captured from Claims Processing -- Data Captured from Case and Utilization Management -- Enrollment Data Sources -- Provider/Practitioner Data Sources -- Authorization Data Sources -- Definition of Database and Claims Payment Information Flows -- Basic MCO Database Information for Authorizations -- Concurrent Review Information Flows -- Episodes-of-Care Information Flows -- Distinction Between Logical and Physical Units of Managed Care Data -- Data and System Security Issues for MCOs -- Differences among Managed Care Reports -- Statistical Indicators Obtainable from Standard MCO Reports -- Planwide Statistics -- Service-Specific (e.g., Psychiatric, Surgical, Obstetric) Statistics -- Provider-Specific Statistics -- Other MCO Statistics -- Integration of Managed Care Databases -- Electronic Connectivity of Managed Care Information -- Conclusion -- ch. 8 Managed Care Legal and Regulatory Compliance -- Introduction -- Federal Regulatory Compliance in Managed Care -- Payer Compliance -- Operational Compliance -- Managed Care Department -- Illegal Gain Sharing -- Illegal Downcoding -- Practitioner Compliance -- Physician Marketers -- Illegal Hospitalist Relationships -- Other Federal Issues -- State Issues -- Typical State Regulatory Requirements of Provider Contracts -- Variable State Regulatory Requirements of Provider Contracts -- State Insolvency Protections -- Compliance in Electronic Transmission of Member Records and Encounters -- Capitation Contractual Issues -- Model HMO Act -- Conclusion -- ch. 9 Innovative Managed Care Modeling for the 21st Century -- pt. A Modeling for Accountable Care Organizations Focusing on Medicare -- Needs Identification for Process Improvement ("Find" Phase) -- Establishing a Team Approach for Process Improvement ("Organize" Phase) -- Establishing Rationales for Process Improvement ("Clarify" Phase) -- Primary Care Access of All Medicare-Certified Physicians -- Inappropriate Primary Care Exclusion of Optometric Physicians -- Root Cause Analyses of Rationales for Process Improvement ("Understand" Phase) -- Biases Against Optometry -- Ignoring the Wellness Model Paradigm --
Contents note continued: Underutilization of Eye Examinations for Systemic Diagnoses -- Ability of Eye Examinations to Reduce Primary Care Fragmentation -- Selection of Implementation Approach to Improve Care Deficits and Cost Savings ("Select" Phase) -- Care Deficits Leading to Potentially Avoidable Expenditures -- Promoting Greater Outpatient Service Efficiencies and Timely Access -- Selected Process Improvement to Implement -- Plan and Program Development to Implement Selected Process Improvement ("Plan" Phase) -- Program Development to Implement Selected Process Improvement -- Medically-Necessary Eye Examinations -- Optometrist Conformance to State Licensure Restrictions -- Establishment of Wellness Components to Individualized Care Plans -- Integrating Optometric Diagnostics with Respective PCMHs -- Importance of Integrating Optometrists with PCMH Team Conferences -- Integrating Optometric Diagnostics with Traditional EHR Archival Data -- Implementation Plan of Selected Process Improvement -- Phased Roll-Out of Implementation Plan Selected for Process Improvement ("Do" Phase) -- Validation of Process Improvement ("Check" Phase) -- Additional Criteria for Program Evaluation -- Action Steps to Re-Initiate the Deming Cycle ("Act" Phase) -- pt. B An At-Risk Disease Management Approach for SSI Recipients -- Background -- Recommended ACO (Or Other At-Risk Approach) for SSI-Funded Chronic Disease Patients -- Medicaid Costs -- Cost-Structuring for Capitated Assumption of SSI Risk -- Positively Impacting Disease Adaptation -- Intended Outcomes of Innovative SSI Risk Approach -- Conclusion -- ch. 10 Innovative MCO Financial Modeling for the 21st Century -- Introduction -- Future Value of Managed Care Contracting: PART 1 -- Veracity of Charges in Managed Care Contracts -- Future Value of Managed Care Contracting: PART 2 -- The Elephant in the Room: How Health Plans Can Compete with State Health Exchanges -- Coming Clean about "Health Maintenance" -- Conclusion---A Final (?) Stroll Down Memory Lane.
- "Thoroughly exploring how capitation has evolved domestically and internationally in recent years, this book discusses actuarial assumptions and the difficulties in payers transitions from community-based underwriting to experience-based ratings. It explores what the future holds in the areas of clinical pathways and population-based risk assumption tools and approaches. It covers what happens when the underlying actuarial and risk assumptions are ignored or trivialized. The author also discusses the challenges capitation-based pricing faces from an international perspective, including Latin America and the Caribbean"--Provided by publisher.
- 9781439840306 (hardcover : alk. paper)
143984030X (hardcover : alk. paper)
- Includes index.
Update of: Capitation / David I. Samuels. c1996.
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