NOT FOR SALE OR DISTRIBUTION Essentials of

1 Essentials of Managed Health Care Study Guide Sixth EditionPeter R. Kongstvedt, MD, FACPS enior Health Policy FacultyDepartment of Health Administration and PolicyGeorge Mason UniversityFairfax, VAPrincipal, Kongstvedt Company, LLCMcLean, i4/2/2012 6:08:52 PM4/2/2012 6:08:52 PM Jones & Bartlett Learning, LLC. not for sale or DISTRIBUTION . 7251 Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning.

2 LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTIONW orld HeadquartersJones & Bartlett Learning5 Wall StreetBurlington, MA & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, discounts on bulk quantities of Jones & Bartlett Learning publications are available to corpora-tions, professional associations, and other qualifi ed organizations. For details and specifi c discount informa-tion, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning CompanyISBN-13: 978-1-4496-0464-6 ISBN-10: 1-4496-0464-1To order this product, use ISBN: 978-1-4496-5331-6 All rights reserved.

3 No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright publication is designed to provide accurate and authoritative information in regard to the Subject Matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the service of a competent professional person should be sought. Essentials of Managed Health Care Study Guide is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this images in this book feature models. These models do not necessarily endorse, represent, or participate in the activities represented in the CreditsPublisher: Michael BrownManaging Editor: Maro GartsideEditorial Assistant: Kayla Dos SantosEditorial Assistant: Chloe FaliveneAssociate Production Editor: Rebekah LingaSenior Marketing Manager: Sophie Fleck TeagueComposition: Laserwords Private Limited, Chennai, IndiaCover Design: Kristin E.

4 ParkerCover Image: Barauskaite/ShutterStock, 15 14 13 12 10 9 8 7 6 5 4 3 2 ii4/2/2012 6:08:53 PM4/2/2012 6:08:53 PM Jones & Bartlett Learning, LLC. not for sale or DISTRIBUTION . 7251 Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning.

5 LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTIONC ontentsPart I: Introduction to Health Insurance and Managed Health CareChapter 1 A History of Managed Health Care and Health Insurance in the United States .. 1 Chapter 2 Types of Health Insurers, Managed Health Care Organizations, and Integrated Health Care Delivery Systems .. 3 Chapter 3 Elements of the Management and Governance Structure .. 8 Part II: Network Contracting and Provider PaymentChapter 4 The Provider Network .. 10 Chapter 5 Provider Payment.. 15 Chapter 6 Legal Issues in Provider Contracting.. 25 Part III: Management of Utilization and QualityChapter 7 Basic Utilization and Case Management .. 27 Chapter 8 Fundamentals and Core Competencies of Disease Management.

6 32 Chapter 9 Physician Practice Behavior and Managed Health Care . 34 Chapter 10 Data Analysis and Provider Profi ling in Health Plans .. 37 Chapter 11 Prescription Drug Benefi ts in Managed Care .. 39 Chapter 12 Introduction to Managed Behavioral Health Care Organizations .. 43 Chapter 13 Disease Prevention in Managed Health Care Plans .. 44 Chapter 14 Quality Management in Managed Health Care .. 46 Chapter 15 Accreditation and Performance Measurement Programs in Managed Health Care .. 48 iii4/2/2012 6:08:53 PM4/2/2012 6:08:53 PM Jones & Bartlett Learning, LLC. not for sale or DISTRIBUTION . 7251 Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning.

7 LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTIONPart IV: Sales, Finance, and AdministrationChapter 16 Marketing and Sales .. 51 Chapter 17 Enrollment and Billing .. 54 Chapter 18 Claims and Benefi ts Administration .. 59 Chapter 19 Health Care Fraud and Abuse .. 62 Chapter 20 Member Services .. 65 Chapter 21 Operational Finance and Budgeting .. 68 Chapter 22 Underwriting and Rating .. 70 Chapter 23 Information Systems and Electronic Data Interchange in Managed Health Care .. 72 Part V: Special MarketsChapter 24 Health Plans and Medicare .. 74 Chapter 25 Medicaid Managed Health Care .. 76 Chapter 26 The Military Managed Care Health System .. 78 Chapter 27 Managed Care in a Global Context.

8 80 Part VI: Laws and RegulationsChapter 28 State Regulation of Managed Care .. 82 Chapter 29 Federal Regulation of Health Insurance and Managed Health Care .. 85 Chapter 30 The Patient Protection and Affordable Care Act .. 89 iv iv4/2/2012 6:08:53 PM4/2/2012 6:08:53 PM Jones & Bartlett Learning, LLC. not for sale or DISTRIBUTION . 7251 Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning.

9 LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION Jones & Bartlett Learning, LLCNOT FOR SALE OR DISTRIBUTION