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Available5.0
12 reviews
ISBN 10: 0429250991
ISBN 13: 9780429250996
Author: David I Samuels
David Samuels, a leading authority on financial models in healthcare, draws on his multidisciplinary background in all aspects of managed care to provide an expansive yet detailed perspective of this complex field. Grounded in evidence-based modeling, the book‘s multidisciplinary focus puts the spotlight on core concepts from the standpoints of hea
1 An Updated Introduction to Managed Care and Capitation
INTRODUCTION
FIGURE 1.1 Is this any way to refer for primary medical eye care?
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
FIGURE 1.2 Forces that worsen (i.e., keep high) medical loss ratios.
FIGURE 1.3 Strategies to improve (i.e., reduce) medical loss ratios.
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
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