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Tables of Contents for Managing Managed Care in the Medical Practice
Chapter/Section Title
Page #
Page Count
1 Managed Care Today
1
14
Perspectives of Managed Care
1
2
Price Discounting
1
1
Utilization Management
1
1
Risk Contracting
2
1
Management Styles for Each Perspective
3
2
Cascading Effect
3
1
Distinct Skill Sets Required
3
3
Utilization Management
4
1
Documentation
4
1
Negotiation
5
1
Risk Contracting
5
1
The Current Environment for Practices
5
1
Anticipating the Needs and Moves of Insurers
6
5
Pressure Is Building on Multiple Fronts
6
4
Table 1-1: HMO Profits for 2001
7
1
Table 1-2: Stock Market Prices for the Top 5 Publicly Held Carriers
7
1
Figure 1-1: Trending of Stock Prices, 1998-2003
7
1
Table 1-3: Changes in Stock Prices by Percentage
8
1
Figure 1-2: Changes for the Top 5 Companies by Percentage
9
1
The Summary Effect
10
1
Understanding a Practice's Market Position
11
1
Demand for Patients vs Capacity
11
1
Influence Over Referrals
12
1
Medical Practice Is Still a Cottage Industry
12
1
A Business Owner's Rights
12
1
The Physician Is Ultimately Responsible for Profit and Success
13
1
Conclusion
13
1
Notes
13
2
2 Developing a Managed Care Strategy
15
24
Specific Identification of the Contracting Parties
15
2
Specifying the Rates and Products
17
1
Maintaining an Exit Strategy
17
2
Benefits to Plans From Long-term Contracts
18
1
Benefit to Practices From Short-term Agreements
18
1
Exit Provisions
19
1
Avoiding All-Products Provisions
19
1
Avoiding "At the Payer's Discretion" Clauses
20
2
Payment Rates
20
1
Figure 2-1: Checklist for All-Product Contracts
20
1
Payment Policies
21
1
Network Leasing or Addition of "Affiliates"
21
1
Figure 2-2: Payment Policy Responses
21
1
Maintaining Complete Files
22
1
Forming a Contract Negotiation Team
22
3
Table 2-1: Payer Contract Inventory
23
1
Figure 2-3: Steps to Improving the Practice's Contracting Efforts
24
1
Table 2-2: Payer Mix: Production
25
1
Table 2-3: Payer Mix: Revenue
25
1
Negotiation Planning
25
8
Timing
26
2
Creative Use of After-Care and Termination Provisions
26
2
Preparation
28
3
The Amount of Volume Purchased
28
1
The Effective Paid Rate vs the Negotiated Rate
29
1
The Effective Rate vs Rates of Other Carriers
29
1
Figure 2-4: Calculating the Difference Between Effective Rate and Negotiated Rate
29
1
What It Will Mean to Walk Away
30
1
Contracting Authority
31
1
The Decision Process for the Practice
31
1
The Decision Process for the Payer
32
1
Additional Thoughts on Negotiation
32
1
ABCs of Language Review
33
3
Timeliness of Payments
36
1
Legal Rights and Boundaries
37
1
Conclusion
37
1
Notes
38
1
3 Providing Cost-effective Health Care
39
12
Maximum Throughput
39
2
Cost per RVU Calculation
41
2
Cost Measurement
41
1
Production Measurement
42
1
Calculation of the Average Cost per RVU
42
1
Using Cost per RVU to Budget
43
6
Revenue per RVU
43
1
Figure 3-1: The 3 Elements That Determine Practice Income
43
1
Overhead Costs
44
2
Physician Compensation as Profit
45
1
Breaking Cost Into Its Component Parts
45
1
Avoiding Too Much Precision
46
1
Production
46
6
Figure 3-2: Benchmarking Resources
47
2
Conclusion
49
1
Note
49
2
4 Billing for Medical Services in a Managed Care Environment
51
26
Managing Managed Care Contracts
52
1
The Claims Process
52
21
Credentialing
52
4
Table 4-1: Quick Reference of Current Managed Care Contracts
53
1
Figure 4-1: The Claims Process
54
2
Information System
56
2
Generating a Clean Claim
58
3
Figure 4-2: Sample Patient Registration Information Sheet
60
1
Coding of Medical Services
61
2
Figure 4-3: Advance Beneficiary Notice
62
1
Charge Entry
63
1
Transmitting Claims
64
4
Figure 4-4: CMS-1500
66
2
Reemphasizing the Need for Clean Claims
68
1
Posting
68
4
Figure 4-5: Explanation of Benefits (EOB)
70
2
Working Open Claims
72
1
Policies and Procedures and Their Documentation
73
1
Conclusion
74
3
Figure 4-6: Billing Function Flowchart
75
2
5 Medicare and Medicaid and Managed Care
77
14
Medicare Managed Care
77
9
Medicare+Choice Plans
78
1
Getting Paid for Services
78
1
Provider-Sponsored Organizations and Medicare Managed Care
79
1
Medicare+Choice and PSOs
79
2
Figure 5-1: Total Medicare Population With Access to Medicare+Choice Private Fee-for-Service Plans, Rural and Urban Counties, 2002-2003
79
2
Figure 5-2: Percentage of Overall Medicare Population in the United States With Access to at Least One Medicare+Choice CCP Plan, 1998-2002
81
1
Participating in Medicare Managed Care Through PSOs
81
1
Payments to PSOs
81
4
Figure 5-3: Seven Steps to Starting a Medicare+Choice PSO
82
2
Payment Based on Geographic Location
84
1
Payment Based on Demographic Adjustments for PSO Enrollees
84
1
Medicare+Choice and Prompt Pay Rules
85
1
PSO Solvency Requirements
85
1
Services Furnished to Enrollees
86
1
Summary of Benefits for 2003 and Major Changes Since 1998
86
1
Medicaid Managed Care
86
3
Figure 5-4: Medicare Fact Sheet
87
1
Problem of Payment Delays
88
1
Proposal to Redesign Medicaid
88
1
Conclusion
89
1
Notes
89
2
6 Risk Contracting
91
12
Risk Readiness
92
3
Contracting
95
5
Implementation
100
1
Conclusion
101
2
7 Ethical Considerations in Managed Care
103
6
The Patient-Physician Relationship
103
1
Conflicts Between Patient and Physician
104
1
Patient Autonomy and Responsibility
105
1
Guidelines From the Council on Ethical and Judicial Affairs
105
2
Conclusion
107
1
Note
107
2
8 HIPAA and Compliance
109
26
Legislative History 109 Privacy Rule Overview
111
2
Strategic Approach to HIPAA Compliance
113
1
Who Must Comply
114
2
Figure 8-1: Strategic Approach to HIPAA Implementation
114
2
Personnel Designations: Privacy Officer and Contact Person
116
2
Policies and Procedures
118
1
Permitted Uses and Disclosures
119
2
Authorizations for Nonpermitted Uses and Disclosures
121
1
Minimum Necessary Rule
122
2
Acknowledgment of Privacy Practices
124
2
Individual Rights
126
2
Training
128
1
Business Associates
128
3
State Law Preemption
131
1
Conclusion
132
1
Notes
133
2
Appendix A Prompt-Pay Statutes and Regulations
135
4
Appendix B AMA Model Managed Care Contract, Third Edition
139
2
Glossary
141
14
Index
155