Managed Care : What It Is and How It Works

Pocket-sized text provides a grounding and clear understanding of managed health care. Much of the information in this text is taken from its parent text, The Managed Health Care Handbook, 4th ed., c2001. Contains learning objectives and a glossary of key managed healthcare terms. Previous edition: c1998. Softcover.

Preface

ix

The Origins of Managed Care

1

(24)

Managed Care: The Early Years (Pre-1970)

1

(4)

The Adolescent Years of Managed Care: 1970-1985

5

(7)

Managed Care as a Mature Concept: 1985-1995

12

(9)

Managed Care in Recent Times

21

(3)

Conclusion

24

(1)

Types of Managed Care Organizations and Their Structure

25

(52)

Types of Bearing Risk for Medical Costs

26

(11)

Payer-Based Managed Care

37

(12)

Integrated Delivery Systems

49

(14)

Governance and Management of MCOs

63

(12)

Conclusion

75

(2)

Network Management and Reimbursement

77

(54)

General Contracting Issues

78

(6)

Physicians

84

(20)

Hospitals and Institutions

104

(23)

Network Maintenance and Management

127

(2)

Conclusion

129

(2)

Medical Utilization and Quality

131

(26)

Prevention and Wellness

132

(1)

Basic Utilization Management

133

(6)

External Review Programs

139

(2)

Disease and Case Management

141

(2)

Ancillary and Pharmaceutical Services

143

(5)

Quality Management

148

(5)

Total Quality Management

153

(2)

Conclusion

155

(2)

Internal Operations

157

(38)

Marketing and Sales

158

(10)

Enrollment and Billing

168

(2)

Claims

170

(9)

Member Services

179

(5)

Finance and Underwriting

184

(9)

Information Systems

193

(1)

Conclusion

194

(1)

Medicare and Medicaid

195

(20)

Medicare

196

(6)

Reimbursement of Medicare+Choice MCOs

202

(1)

Special Requirements for Medicare+Choice MCOs

203

(8)

Medicaid

211

(3)

Conclusion

214

(1)

Regulation and Accreditation in Managed Care

215

(28)

State Regulation

216

(8)

The Health Insurance Portability and Accountability Act

224

(13)

Self-Insured Employers and the Employee Retirement Income Security Act

237

(1)

Accreditation of Managed Care Organizations

238

(4)

Conclusion

242

(1)

Epilogue: Managed Health Care at the Millennium

243

(16)

Glossary

259

(50)

Index

309

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Managed Care : What It Is and How It Works

Summary

Table of Contents

Supplemental Materials