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Managed Care

Managed Care

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Published by: ocirs on Feb 27, 2008
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A Better CEAll Rights Reserved, Richard Levine 1
A BETTER CE
MANAGED CARE
Lecture
MANAGED CARE.........................................................................................................................1Section 1..........................................................................................................................................5I. THE NATURE OF MANAGED CARE.................................................................................5A. THE IMPORTANCE OF HEALTH INSURANCE..........................................................5B. BASIC BUILDING BLOCKS OF HEALTH COVERAGE.........................................6C. COMPREHENSIVE MAJOR MEDICAL POLICIES..................................................6D. ABOUT MANAGED CARE.........................................................................................7E. Managed Care Is the System We Have Today...............................................................8F. PURPOSE OF MANAGED CARE................................................................................8G. THE OLD METHOD OF COVERING HEALTH COST.............................................9II. A NEW APPROACH.........................................................................................................9A. THE NEW METHOD OF COVERING HEALTH COST............................................9B. COST VS. CHOICE.....................................................................................................10III. HOW THE SYSTEM OPERATES................................................................................10A. PROCEDURES IN MANAGED CARE......................................................................11B. COORDINATION IN MANAGING THE CASE.......................................................11C. AHEAD OF THE CURVE...........................................................................................11D. BENEFITS OF MANAGING INFORMATION.........................................................12E. MAKING THE DOCTOR RESPONSIBLE FOR HEALTHCARE DECISIONS......12F. GATEKEEPER, THE PRIMARY CARE PHYSICIAN..............................................12G. CLAIM FORMS BY PROVIDER RATHER THAN BY PATIENT..........................13H. PREVENTING AN ILLNESS IS A FAR BIGGER VICTORY THAT CURING ONE............................................................................................................................................13IV. HEALTH MANAGEMENT ORGANIZATIONS.........................................................14A. NEW CAPITAL FORMATIONS IN HEALTH CARE..............................................14B. NATURE OF CONTRACTS WITH PROVIDERS: CONTROL VS. COST.............14C. CONSUMER SATISFACTION BASED ON TYPE OF PLAN.................................17V. COST CONTROL BY MANAGED CARE....................................................................18A. THE SHIFT TO OUTPATIENT CARE......................................................................18B. CONTROLLING THE COST OF PHARMACEUTICALS........................................18C. COST CONTROL FOR MENTAL CONDITION TREATMENT.............................20D. THE HISTORY OF “USUAL CUSTOMARY AND REASONABLE”.....................20E. INCENTIVES TO THE PROVIDER/CONTROL BY PREMIUM PAYER..............21F. THE PREADMISSION REVIEW CONTROL............................................................21G. CONTROLLING LENGTH OF HOSPITAL STAY...................................................22H. SECOND SURGICAL OPINION................................................................................22I. LARGE CASE MANAGEMENT.................................................................................23
 
A Better CEAll Rights Reserved, Richard Levine 2J. ADDITIONAL MANAGED CARE ORGANIZATION SERVICES..........................23K. 24/7/365 PATIENT SUPPORT HOTLINE.................................................................23L. WORKERS COMPENSATION..................................................................................23M. MAKING SURE THE PROVIDER IS TRULY QUALIFIED...................................24 N. HOW THE PROVIDER IS PAID................................................................................24O. BETTER MANAGEMENT MEANS LOWER-COST...............................................25VI. THE LEGAL STANDING OF MANAGED CARE ORGANIZATIONS....................25A. THE LEGISLATIVE CLIMATE.................................................................................25B. MEDICARE AND HMOS...........................................................................................26C. ADVANTAGES TO THE COVERAGE LIVES.........................................................26D. MANAGED CARE ORGANIZATIONS CAREFULLY CREDENTIALPROVIDERS.....................................................................................................................27VII.
VARIATIONS ON THE HMO THEME
PREFERRED PROVIDER ORGANIZATIONS..............................................................................................................27A. DESCRIPTIONS OF PREFERRED PROVIDER ORGANIZATIONS...PPOs.........27B. VARYING FINANCIAL INCENTIVES FOR PPO PATIENTS................................29C. THE MARKET FOR THE PLAN...............................................................................29D. EXCLUSIVE PROVIDER ORGANIZATIONS... EPOS...........................................29VIII. POINT OF SERVICE PLANS....POS.........................................................................30A. COVERED PERSONS UTILIZATION OF A PLAN.................................................30B. MORE STEERAGE.....................................................................................................30C. ORIGINS OF THE POS PLAN...................................................................................31D. SOME DISADVANTAGES OF POS..........................................................................31E. A CONCERN FOR AGENTS......................................................................................32IX. CREDENTIALING........................................................................................................32A. CREDENTIALING MCOs..........................................................................................32B. CREDENTIALING PROVIDERS...............................................................................34C. AMERICAN MEDICAL ASSOCIATION (AMA) PHYSICIAN PERFORMANCEASSESSMENT PROGRAM............................................................................................35D. NATIONAL PRACTITIONER DATA BANK...........................................................35E. THE PHYSICIAN’S FINANCIAL PROFILE.............................................................35F. MANAGING BY RESULTS VS. MANAGING BY COST.......................................36X. EVALUATING THE PLANS.........................................................................................36A. UTILIZATION REVIEW ACCREDITATION COMMISSION (URAC).................36B. AMERICAN ACCREDITATION PROGRAM, INC (AAPI).....................................37C. JOINT COMMISSION ON ACCREDITATION OF HEALTH CAREORGANIZATIONS..........................................................................................................37D. UTILIZATION REVIEW ACCREDITATION COMMISSION... URAC.................37E. THE NATIONAL COMMITTEE FOR QUALITY ASSURANCE... NCQA.............38XI. MEDICAL SAVINGS ACCOUNTS.............................................................................39A. DESCRIPTION OF MEDICAL SAVINGS ACCOUNTS.........................................39B. HISTORY OF MSA ACCOUNTS..............................................................................41C. HIPAA AND MEDICAL SAVINGS ACCOUNTS....................................................42D. THE MSA CONFLICTS WITH MANAGED-CARE.................................................43
 
A Better CEAll Rights Reserved, Richard Levine 3XII. THE INDIVIDUAL MARKET.....................................................................................43A. AGENT RESPONSIBILITY WHEN GROUP COVERAGE NO LONGER APPLIESTO A CHILD....................................................................................................................43B. CATASTROPHIC HEALTH INSURANCE- WHO BUYS IT?.................................44C. SHORT-TERM HEALTH INSURANCE....................................................................44D. AN ETHICAL APPROACH........................................................................................45E. OTHER OPTIONS FOR YOUNG PEOPLE...............................................................46F. HEALTH REINSURANCE ASSOCIATION..............................................................46G. NEW MARKETS FOR INSURANCE AGENTS.......................................................46H. ACCIDENT AND HEALTH INSURANCE FOR HOME BUSINESS OWNERS....47XIII. EMPLOYER ISSUES..................................................................................................47A. THE RIGHT BROKER................................................................................................47B. THE EMPLOYERS FINANCIAL EXPOSURE.........................................................49C. EMPLOYER ISSUES IN SELECTING A GROUP HEALTH CARRIER................49D. HEALTH SAVINGS ACCOUNTS.............................................................................50E. EMPLOYER QUALITY PARTNERSHIP..................................................................50F. WHO IS PAYING ATTENTION TO HEALTHCARE REPORTS?..........................51G. REPORTS ON THE PHYSICIANS............................................................................51H. BUYING POWER FOR THE SMALL BUSINESS. PEOs.......................................52I. COMPARING TRADITIONAL HEALTH PLANS TO PEOs....................................52J. THE BUSINESS MANAGERS APPROACH..............................................................53
XIV.
COMPARISON TO OTHER COUNTRIES................................................................54A. COMPARISON TO CARE IN ENGLAND AND EUROPE......................................54XV. LAW REGULATIONS AND ETHICS........................................................................56A. WHICH HMO WILL THE ETHICAL AGENT PRODUCE FOR?...........................56B. HOW WELL ACCREDITED IS THE HMO?.............................................................57C. HOW GOOD ARE THE PROVIDERS?.....................................................................57D. WHO MAKES THE CARE DECISIONS?.................................................................57E. ARE BENEFITS RESTRICTED?................................................................................58F. FEDERAL OR STATE REGULATION?....................................................................59G. ERISA AND HEALTH PLAN REGULATION.........................................................60H. A GREAT DANGER FOR AGENTS AND INSURERS............................................61Section 2........................................................................................................................................61I. WORKING ETHICALLY WITH THE CLIENT.............................................................61A. EMPLOYERS VIEW OF HEALTH INSURANCE:...................................................61B. CONSIDER HOW EMPLOYEES FEEL ABOUT THE PLAN.................................62B. CONSIDER THE POLICY OF EACH ORGANIZATION........................................63C. CONSUMER REPORTS.............................................................................................64D. THE SOUL OF AN HMO............................................................................................65E. WHEN THE HOSPITAL BEHAVES UNETHICALLY.............................................66F. COBRA.........................................................................................................................67G. INITIATING COBRA COVERAGE...........................................................................69H. AGENT RESPONSIBILITIES AND COBRA............................................................69I. ADDITIONAL COBRA RULES:.................................................................................70

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