Essentials of Managed Care (Book with Access Code)

by Kongstvedt, Peter R.

• ISBN13: 9781449653316
• ISBN10: 1449653316
• Edition: 6th
• Format: Paperback w/ Access Code
• Copyright: 2012-04-20
• Publisher: Jones & Bartlett Learning

Summary

As the most widely-used textbook on managed care, Essentials of Managed Health Care provides an authoritative and comprehensive overview of the key strategic, tactical, and operational aspects of managed health care and health insurance. With a primary focus on the commercial sector, the book also addresses managed health care in Medicare, Medicaid, and military medical care. An historical overview and a discussion of taxonomy and functional differences between different forms of managed health care provide the framework for the operational aspects of the industry as well.The Sixth Edition is a thorough revision that addresses the impact of HR 3590, the Patient Protection and Affordable Care Act, as well as other new laws such as the Genetic Information Non-disclosure Act (GINA).

Table of Contents

Introduction1 Introduction
PartOne Introduction to Health Insurance and Managed Health Care
Chapter1 A History of Managed Health Care and Health Insurance in the United States By Pete Fox and Peter R. Kongstvedt
Chapter2 Types of Health Insurers, Managed Health Care Organizations and Integrated Healthcare Delivery Systems By Eric Wagner and Peter R. Kongstvedt
Chapter3 Elements of the Management and Governance Structure By Peter R. Kongstvedt
PartTwo Network Contracting and Provider Payment
Chapter4 The Provider Network By Peter R. Kongstvedt
Chapter5 Provider Payment By Peter R. Kongstvedt
Chapter6 Legal Issues in Provider Contracting By Mark S. Joffe and Kelli D. Back
PartThree Management of Utilization and Quality
Chapter7 Basic Utilization and Case Management By Peter R. Kongstvedt
Chapter8 Fundamentals and Core Competencies of Disease Management By David W. Plocher
Chapter9 Physician Practice Behavior and Managed Health Care By Jay Want and Peter R. Kongstvedt
Chapter10 Data Analysis and Provider Profiling in Health Plans By David W. Plocher & Nancy Garrett
Chapter11 Prescription Drug Benefits in Managed Care By Robert P. Navarro, Craig Stern, and Rusty Hailey
Chapter12 Introduction to Managed Behavioral Healthcare Organizations By Joann Albright, Deborah Heggie, Anthony M. Kotin, Connie Salgy, Wanda Sullivan, and Fred Waxenberg
Chapter13 Disease Prevention in Managed Health Care Plans By Mark Manley
Chapter14 Quality Management in Managed Health Care By Pamela B. Siren
Chapter15 Accreditation and Performance Measurement Programs in Managed Health Care By Margaret E. O'Kane
PartFour Sales, Finance and Administration
Chapter16 Marketing and Sales By Richard Birhanzel
Chapter17 Enrollment and Billing By Karl V. Kovacs
Chapter18 Claims and Benefits Administration By Donald L. Fowler, Jr. and Elizabeth Pascuzzi
Chapter19 Health Care Fraud and Abuse By Christie Moon
Chapter20 Member Services By Kevin Knarr and Peter R. Kongstvedt
Chapter21 Operational Finance and Budgeting By Dale F. Cook and Christopher Campbell
Chapter22 Underwriting and Rating By Michael G. Sturm and Troy M. Filipek
Chapter23 Information Systems and Electronic Data Interchange in Managed Health Care By James S. Slubowski
PartFive Special Markets
Chapter24 Health Plans and Medicare By John K. Gorman, Jean D. LeMasurier, William A. MacBain, Stephen J. Balcerzak, Wendy K. Burger and Amy Huang
Chapter25 Medicaid Managed Health Care By Rodney C. Armstead, Catherine K. Anderson, Elizabeth Cabot Nash
Chapter26 The Military Managed Care Health System By M. Nicholas Coppola, Ronald P. Hudak, Forest S. Kim, Lawrence Fulton, Jeffrey P. Harrison, and Bernie Kerr
Chapter27 Managed Care in a Global Context By Jonathan P. Weiner, Emily Adrion, Joanna Case Famadas, Djordje Gikic and Hugh Waters
PartSix Laws and Regulations
Chapter28 State Regulation of Managed Health Care By Tom Wilder
Chapter29 Federal Regulation of Health Insurance and Managed Health Care By Tom Wilder
Chapter30 The Patient Protection and Affordable Care Act By Tom Wilder