Kongstvedt Peter R. (ed.) Essentials of Managed Health Care

6th edition. — Jones & Bartlett Learning, 2013. — 1001 p.As the most widely-used textbook on managed care, Essentials of Managed Health Care provides an authoritative and comprehensive overview of the key strategic, tactical, and operational aspects of managed health care and health insurance. With a primary focus on the commercial sector, the book also addresses managed health care in Medicare, Medicaid, and military medical care. An historical overview and a discussion of taxonomy and functional differences between different forms of managed health care provide the framework for the operational aspects of the industry as well.Introduction to Health Insurance and Managed Health Care
A History of Managed Health Care and Health Insurance in the United States
Types of Health Insurers, Managed Health Care Organizations and Integrated Healthcare Delivery Systems
Elements of the Management and Governance Structure
Network Contracting and Provider Payment
The Provider Network
Provider Payment
Legal Issues in Provider Contracting
Management of Utilization and Quality
Basic Utilization and Case Management
Fundamentals and Core Competencies of Disease Management
Physician Practice Behavior and Managed Health Care
Data Analysis and Provider Profiling in Health Plans
Prescription Drug Benefits in Managed Care
Introduction to Managed Behavioral Healthcare Organizations
Disease Prevention in Managed Health Care Plans
Quality Management in Managed Health Care
Accreditation and Performance Measurement Programs in Managed Health Care
Sales, Finance and Administration
Marketing and Sales
Enrollment and Billing
Claims and Benefits Administration
Health Care Fraud and Abuse
Member Services
Operational Finance and Budgeting
Underwriting and Rating
Information Systems and Electronic Data Interchange in Managed Health Care
Special Markets
Health Plans and Medicare
Medicaid Managed Health Care
The Military Managed Care Health System
Managed Care in a Global Context
Laws and Regulations
State Regulation of Managed Health Care
Federal Regulation of Health Insurance and Managed Health Care
The Patient Protection and Affordable Care Act