Managing Managed Care in the Medical Practice Book

1	Managed Care Today	1
	Perspectives of Managed Care	1
	Management Styles for Each Perspective	3
	The Current Environment for Practices	5
2	Developing a Managed Care Strategy	15
	Specific Identification of the Contracting Parties	15
	Specifying the Rates and Products	17
	Maintaining an Exit Strategy	17
	Avoiding All-Products Provisions	19
	Avoiding "At the Payer's Discretion" Clauses	20
	Maintaining Complete Files	22
	Forming a Contract Negotiation Team	22
	Negotiation Planning	25
	ABCs of Language Review	33
	Timeliness of Payments	36
	Legal Rights and Boundaries	37
3	Providing Cost-effective Health Care	39
	Maximum Throughput	39
	Cost per RVU Calculation	41
	Using Cost per RVU to Budget	43
4	Billing for Medical Services in a Managed Care Environment	51
	Managing Managed Care Contracts	52
	The Claims Process	52
	Policies and Procedures and Their Documentation	73
5	Medicare and Medicaid and Managed Care	77
	Medicare Managed Care	77
	Medicaid Managed Care	86
6	Risk Contracting	91
	Risk Readiness	92
	Contracting	95
	Implementation	100
7	Ethical Considerations in Managed Care	103
	The Patient-Physician Relationship	103
	Conflicts Between Patient and Physician	104
	Patient Autonomy and Responsibility	105
	Guidelines From the Council on Ethical and Judicial Affairs	105
8	HIPAA and Compliance	109
	Legislative History	109
	Privacy Rule Overview	111
	Strategic Approach to HIPAA Compliance	113
	Who Must Comply	114
	Personnel Designations: Privacy Officer and Contact Person	116
	Policies and Procedures	118
	Permitted Uses and Disclosures	119
	Authorizations for Nonpermitted Uses and Disclosures	121
	Minimum Necessary Rule	122
	Acknowledgment of Privacy Practices	124
	Individual Rights	126
	Training	128
	Business Associates	128
	State Law Preemption	131
App. A	Prompt-Pay Statutes and Regulations	135
App. B	AMA Model Managed Care Contract, Third Edition	139
	Glossary	141
	Index	155