Managed Health Care in the New Millennium: Innovative Financial Modeling for the 21st Century

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 Understanding Managed Care Industry Operations Introduction To The Insurance Industry Understanding ERISA Implications for HMOs and Employers Introduction to Managed Care Underwriting Introduction to Commercially Insured Populations Understanding Rating Methodologies: Community Versus Experience Understanding and Predicting Medical Losses Introduction to Actuarial Mathematics Premium and Product Issues Employer Benefit Plan Design Payer-Provider Risk Relationships Stop-Loss and PMPM Relationships Other Interrelationships Risk Banding and Provider Risk-Sharing Arrangements Payer-Provider Financial Relationships Claims Management and Processing Referral Management Payer Development of Provider Panels Outcomes Reporting Advanced Studies in Capitated Managed Care Understanding of Operational Capitation for the Healthcare Industry Conclusion Managed Care Provider and Practitioner Operations Introduction The Board of Directors Payer Benefit Determination MCO Economics Specialty HMOs Federal Qualification Eligibility by Office for Managed Care MCO Marketing and Product Development Revenue Drivers Based on Requests for Proposal and Requests for Information Payer and Practitioner/Provider Services Strategies to Manage Provider/Practitioner Costs Payer/Provider Budgeting and Financial/Resource Estimation Conclusion Managed Care Organization Quality Benchmarking Introduction Accreditation of HMOs Under NCQA URAC Accreditation Procedures Accreditation of Preferred Provider Organizations 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: Healthcare Finance's Best Response to Six Sigma Conclusion Managing the Managed Care Enrollee Introduction Managed Care Expectations of Enrollees Managed Care Enrollee Access and Accessibility Modeling 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 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 Typical Member Rights and Responsibilities Conclusion 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 Managed Care-Specific Financial Indicators MCO Internal Control Conclusion Management of Managed Care Information for Modeling Purposes Introduction Data Elements and Sources Definition of Database and Claims Payment Information Flows Distinction Between Logical and Physical Units of Managed Care Data Data and System Security Issues for MCOs Differences Among Managed Care Reports Integration of Managed Care Databases Electronic Connectivity of Managed Care Information Conclusion Managed Care Legal and Regulatory Compliance Introduction Federal Regulatory Compliance in Managed Care State Issues Compliance in Electronic Transmission of Member Records and Encounters Capitation Contractual Issues Model HMO Act Conclusion Innovative Managed Care Modeling for the 21st Century Part A: Modeling for Accountable Care Organizations Focusing on Medicare Needs Identification for Process Improvement (Find Establishing Team Approach for Process Improvement (Organize Phase) Establishing Rationales for Process Improvement (Clarify Phase) Root Cause Analyses of Rationales for Process Improvement (Understand Phase) Selection of Implementation Approach to Improve Care Deficits and Cost Savings (Select Phase) Plan and Program Development to Implement Selected Process Improvement (Plan Phase of Deming's Cycle) Roll-Out of Implementation Plan Selected for Process Improvement (Do Phase) Validation of Process Improvement (Check Phase) Action Steps to Re-initiate the Deming Cycle (Act Phase) Part B: An At-Risk Disease Management Approach for SSI Recipients Conclusion Innovative MCO Financial Modeling for the 21st Century Introduction Future Value of Managed Care Contracting: Part 1 Future Value of Managed Care Contracting: Part 2 Conclusion: A Final Walk Down Memory Lane Index