Preface |
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xv | |
Acknowledgments |
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xix | |
About the Author |
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xxi | |
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Chapter 1 An Updated Introduction to Managed Care and Capitation |
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1 | (24) |
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1 | (4) |
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A Simple Definition---But Not So Simple History---Of Managed Care and Capitation |
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5 | (1) |
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Understanding Managed Care in the Private and Public Sectors: A Reality Check |
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6 | (4) |
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Understanding Capitation---And Not Just Financially |
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10 | (4) |
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Effects of Public Policies on Capitation and Capitated Relationships |
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14 | (2) |
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A Simplified Understanding of Managed Care Models |
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16 | (1) |
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Two Basic Demand Models of Managed Care: Illness-Based versus Wellness-Based |
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16 | (1) |
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Understanding Health Plans |
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17 | (8) |
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Chapter 2 Understanding Managed Care Industry Operations |
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25 | (62) |
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Introduction to the Insurance Industry |
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25 | (2) |
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Understanding ERISA Implications for HMOs and Employers |
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27 | (2) |
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Responsibility for Negligence under ERISA |
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27 | (1) |
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Administration of Practice Management |
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27 | (1) |
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Credentialing of Network Providers |
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28 | (1) |
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Actions of Employed Staff/Practitioners |
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28 | (1) |
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Contractual Liability Issues |
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28 | (1) |
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Unreasonable Benefit Determination |
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29 | (1) |
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Balance-Billing Violations of FQHMOs |
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29 | (1) |
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Introduction to Managed Care Underwriting |
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29 | (3) |
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30 | (1) |
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30 | (1) |
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30 | (1) |
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31 | (1) |
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31 | (1) |
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31 | (1) |
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Introduction to Commercially Insured Populations |
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32 | (2) |
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32 | (1) |
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Control of Commercial Risk Populations |
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33 | (1) |
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Understanding Rating Methodologies: Community versus Experience |
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34 | (6) |
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34 | (1) |
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34 | (2) |
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Community Ratings by Class |
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36 | (2) |
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Experience Rating Methodologies |
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38 | (2) |
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Experience-Based Community Ratings |
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40 | (1) |
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Understanding and Predicting Medical Losses |
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40 | (2) |
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Introduction to Actuarial Mathematics |
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42 | (1) |
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Premium and Product Issues |
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43 | (1) |
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43 | (1) |
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Payer Nonoperating Revenue Sources |
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43 | (1) |
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Employer Benefit Plan Design |
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44 | (3) |
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Cost-Sharing Impacts on Product Design |
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45 | (1) |
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45 | (1) |
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45 | (1) |
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46 | (1) |
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Incentives and Disincentives |
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46 | (1) |
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47 | (1) |
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Cost Data to Predict Losses |
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47 | (3) |
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Community Utilization and Service Intensities |
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48 | (1) |
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Impact of Utilization Management |
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48 | (1) |
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Effectiveness of Health Care Management |
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48 | (1) |
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Probability Matrix of Predicted Use |
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48 | (1) |
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48 | (1) |
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MCO Operational Elements to Minimize Losses |
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49 | (1) |
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Payer-Provider Risk Relationships |
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50 | (1) |
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Stop-Loss and PMPM Relationships |
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51 | (3) |
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Underwriting and Reinsurance Relationships |
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52 | (2) |
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54 | (1) |
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Risk Banding and Provider Risk-Sharing Arrangements |
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55 | (2) |
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Payer-Provider Financial Relationships |
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57 | (2) |
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57 | (1) |
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58 | (1) |
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58 | (1) |
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"Pursue-and-Pay" COB Method |
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59 | (1) |
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"Pay-and-Pursue" COB Method |
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59 | (1) |
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Capitation Adjustments Based on Percentage of Premium Revenue |
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59 | (5) |
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Claims Management and Processing |
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60 | (3) |
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63 | (1) |
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64 | (6) |
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64 | (3) |
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Prospective Authorizations |
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67 | (1) |
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Concurrent Authorizations |
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68 | (1) |
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Retrospective Authorizations |
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69 | (1) |
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69 | (1) |
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69 | (1) |
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Subordinate ("Sub-") Authorizations |
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70 | (1) |
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Payer Development of Provider Panels |
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70 | (1) |
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71 | (1) |
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Advanced Studies in Capitated Managed Care |
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72 | (9) |
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73 | (3) |
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76 | (1) |
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77 | (1) |
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Gatekeeping and Primary Care Capitation |
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78 | (1) |
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Contact and Specialty Care Capitation |
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78 | (1) |
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79 | (1) |
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80 | (1) |
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81 | (1) |
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Understanding of "Operational" Capitation for the Health Care Industry |
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81 | (4) |
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85 | (2) |
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Chapter 3 Managed Care Provider and Practitioner Operations |
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87 | (26) |
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87 | (1) |
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87 | (2) |
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89 | (1) |
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89 | (3) |
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89 | (2) |
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91 | (1) |
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91 | (1) |
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91 | (1) |
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91 | (1) |
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91 | (1) |
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General Counsel/Compliance |
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92 | (1) |
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Payer Benefit Determination |
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92 | (1) |
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92 | (1) |
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93 | (1) |
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93 | (1) |
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Federal Qualification Eligibility by Office for Managed Care |
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93 | (4) |
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Application Process for FQHMO Qualification |
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95 | (1) |
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Site Visit Prior to FQHMO Qualification |
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96 | (1) |
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FQHMO Postqualification Process |
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96 | (1) |
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MCO Marketing and Product Development |
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97 | (3) |
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Market Segmentation Strategies |
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97 | (1) |
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Defining Desirable Market Segments |
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98 | (1) |
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Strategic Product-Positioning Drivers |
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99 | (1) |
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Distribution Channel Drivers of Effective Product Placement |
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99 | (1) |
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Revenue Drivers Based on Requests for Proposal and Requests for Information |
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100 | (1) |
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100 | (1) |
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100 | (1) |
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Payer and Practitioner/Provider Services |
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101 | (3) |
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101 | (2) |
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Carve-Outs versus Carve-Ins |
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103 | (1) |
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103 | (1) |
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Strategies to Manage Provider/Practitioner Costs |
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104 | (2) |
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104 | (1) |
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Episodes-of-Care Profiling |
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105 | (1) |
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Incentive Compensation Data |
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105 | (1) |
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Payer/Provider Budgeting and Financial/Resource Estimation |
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106 | (5) |
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106 | (1) |
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Analyses of Administrative Costs |
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106 | (1) |
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Analyses of Capitated Medical Service Costs |
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106 | (1) |
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Analyses of Fee-for-Service Practitioner Costs |
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107 | (1) |
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108 | (1) |
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Nonnetwork and Referral Services Data |
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108 | (1) |
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Hospital Inpatient Utilization/Payment Data |
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108 | (2) |
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110 | (1) |
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111 | (2) |
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Chapter 4 Managed Care Organization Quality Benchmarking |
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113 | (22) |
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113 | (1) |
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Accreditation of HMOs under NCQA |
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114 | (7) |
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NCQA Accreditation Process |
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115 | (1) |
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116 | (2) |
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Clinical Indicators Measured through MCO Accreditation |
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118 | (1) |
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Joint Commission Quality Indicators |
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118 | (1) |
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Health-Plan Employer Data and Information Set |
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118 | (3) |
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URAC Accreditation Procedures |
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121 | (3) |
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URAC Accreditation Process |
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121 | (1) |
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121 | (2) |
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123 | (1) |
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123 | (1) |
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123 | (1) |
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Appeals of Denied Authorizations |
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123 | (1) |
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123 | (1) |
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Staff and Program Requirements |
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124 | (1) |
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124 | (1) |
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Accreditation of Preferred Provider Organizations |
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124 | (1) |
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124 | (1) |
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125 | (1) |
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Introduction to Six Sigma Quality Benchmarking Methodology |
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125 | (3) |
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Quality Improvement and Benchmarking Approach for Six Sigma |
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128 | (1) |
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Utilizing Six Sigma Benchmarking in MCO Operations |
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129 | (2) |
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Learning from Clinicians: Health Care Finance's Best Response to Six Sigma |
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131 | (1) |
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132 | (3) |
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Chapter 5 Managing the Managed Care Enrollee |
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135 | (28) |
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135 | (2) |
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Managed Care Expectations of Enrollees |
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137 | (3) |
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Managed Care Enrollee Access and Accessibility Modeling |
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140 | (5) |
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Accessibility to Appropriate Specialty Care |
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142 | (1) |
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Provider/Practitioner Autonomy |
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143 | (1) |
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Access to Non-Allopaths and Allied Health Professionals |
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144 | (1) |
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145 | (1) |
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Managed Care Quality at the Enrollee Level |
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146 | (5) |
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Managed Care Enrollee Impacts on Provider/Practitioner Costs |
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151 | (3) |
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Health Guidance Services for Managed Care Enrollees |
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154 | (1) |
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Community-Based Health Information |
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154 | (1) |
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Payer- or MCO-Provided Consumer Education |
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154 | (1) |
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Enrollee Health Guidance Internet Sites |
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154 | (1) |
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Enrollee Responsibility to Comply with Strategies for Treatment, Disease Adaptation, Health Status Improvement, and Healthiness Management |
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155 | (1) |
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Appropriateness of Provider Resource Utilization of Enrollees |
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156 | (1) |
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Methods of Transforming Behavior of Capitated Enrollees |
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157 | (3) |
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Lifestyle Improvement Contracts |
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158 | (1) |
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Incentivizing Enrollee Compliance |
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159 | (1) |
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Establishing Enrollee "Feedback Loops" |
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160 | (1) |
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Typical Member Rights and Responsibilities |
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160 | (2) |
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MCO Responsibilities for Improper Care |
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160 | (1) |
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MCO Contractual Responsibilities to Enrollees |
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161 | (1) |
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162 | (1) |
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Chapter 6 Enrollee-Based Financial and Mathematical Prediction Models |
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163 | (14) |
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163 | (1) |
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Overview of Case Management/Utilization Management |
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163 | (2) |
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Use of Financial Data Derived from CM/UM |
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165 | (1) |
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Incurred-but-Not-Reported Case Management Data |
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165 | (7) |
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Indicators of Inappropriate IBNR Levels |
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166 | (1) |
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166 | (3) |
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169 | (1) |
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169 | (1) |
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170 | (1) |
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170 | (1) |
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171 | (1) |
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171 | (1) |
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171 | (1) |
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Managed Care-Specific Financial Indicators |
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172 | (2) |
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173 | (1) |
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173 | (1) |
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173 | (1) |
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173 | (1) |
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174 | (1) |
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174 | (1) |
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Controlling Claims by Linking to Authorizations |
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174 | (1) |
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PCP Cooperation in Enhancing Controls |
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175 | (1) |
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175 | (2) |
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Chapter 7 Management of Managed Care Information for Modeling Purposes |
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177 | (16) |
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177 | (1) |
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Data Elements and Sources |
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178 | (5) |
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Data Captured from Claims Processing |
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179 | (1) |
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Data Captured from Case and Utilization Management |
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179 | (1) |
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180 | (1) |
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Provider/Practitioner Data Sources |
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181 | (1) |
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Authorization Data Sources |
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181 | (2) |
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Definition of Database and Claims Payment Information Flows |
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183 | (2) |
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Basic MCO Database Information for Authorizations |
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184 | (1) |
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Concurrent Review Information Flows |
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184 | (1) |
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Episodes-of-Care Information Flows |
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185 | (1) |
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Distinction Between Logical and Physical Units of Managed Care Data |
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185 | (1) |
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Data and System Security Issues for MCOs |
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186 | (1) |
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Differences among Managed Care Reports |
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186 | (3) |
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Statistical Indicators Obtainable from Standard MCO Reports |
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186 | (1) |
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187 | (1) |
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Service-Specific (e.g., Psychiatric, Surgical, Obstetric) Statistics |
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187 | (1) |
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Provider-Specific Statistics |
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188 | (1) |
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188 | (1) |
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Integration of Managed Care Databases |
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189 | (1) |
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Electronic Connectivity of Managed Care Information |
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190 | (1) |
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191 | (2) |
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Chapter 8 Managed Care Legal and Regulatory Compliance |
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193 | (28) |
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193 | (1) |
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Federal Regulatory Compliance in Managed Care |
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193 | (18) |
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193 | (8) |
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201 | (1) |
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201 | (2) |
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203 | (4) |
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207 | (1) |
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208 | (1) |
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208 | (1) |
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Illegal Hospitalist Relationships |
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209 | (2) |
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211 | (1) |
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211 | (3) |
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Typical State Regulatory Requirements of Provider Contracts |
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212 | (1) |
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Variable State Regulatory Requirements of Provider Contracts |
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213 | (1) |
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State Insolvency Protections |
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213 | (1) |
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Compliance in Electronic Transmission of Member Records and Encounters |
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214 | (3) |
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Capitation Contractual Issues |
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217 | (1) |
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218 | (1) |
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219 | (2) |
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Chapter 9 Innovative Managed Care Modeling for the 21st Century |
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221 | (28) |
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Part A Modeling for Accountable Care Organizations Focusing on Medicare |
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221 | (1) |
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Needs Identification for Process Improvement ("Find" Phase) |
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222 | (1) |
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Establishing a Team Approach for Process Improvement ("Organize" Phase) |
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222 | (1) |
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Establishing Rationales for Process Improvement ("Clarify" Phase) |
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223 | (4) |
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Primary Care Access of All Medicare-Certified Physicians |
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223 | (1) |
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Inappropriate Primary Care Exclusion of Optometric Physicians |
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224 | (3) |
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Root Cause Analyses of Rationales for Process Improvement ("Understand" Phase) |
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227 | (5) |
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227 | (1) |
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Ignoring the Wellness Model Paradigm |
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228 | (1) |
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Underutilization of Eye Examinations for Systemic Diagnoses |
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228 | (3) |
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Ability of Eye Examinations to Reduce Primary Care Fragmentation |
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231 | (1) |
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Selection of Implementation Approach to Improve Care Deficits and Cost Savings ("Select" Phase) |
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232 | (2) |
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Care Deficits Leading to Potentially Avoidable Expenditures |
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233 | (1) |
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Promoting Greater Outpatient Service Efficiencies and Timely Access |
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233 | (1) |
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Selected Process Improvement to Implement |
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234 | (1) |
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Plan and Program Development to Implement Selected Process Improvement ("Plan" Phase) |
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234 | (5) |
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Program Development to Implement Selected Process Improvement |
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234 | (1) |
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Medically-Necessary Eye Examinations |
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234 | (1) |
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Optometrist Conformance to State Licensure Restrictions |
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234 | (1) |
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Establishment of Wellness Components to Individualized Care Plans |
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234 | (1) |
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Integrating Optometric Diagnostics with Respective PCMHs |
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234 | (1) |
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Importance of Integrating Optometrists with PCMH Team Conferences |
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234 | (4) |
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Integrating Optometric Diagnostics with Traditional EHR Archival Data |
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238 | (1) |
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Implementation Plan of Selected Process Improvement |
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238 | (1) |
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Phased Roll-Out of Implementation Plan Selected for Process Improvement ("Do" Phase) |
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239 | (2) |
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Validation of Process Improvement ("Check" Phase) |
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241 | (1) |
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Additional Criteria for Program Evaluation |
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242 | (1) |
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Action Steps to Re-Initiate the Deming Cycle ("Act" Phase) |
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242 | (1) |
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Part B An At-Risk Disease Management Approach for SSI Recipients |
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242 | (7) |
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242 | (1) |
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Recommended ACO (Or Other At-Risk Approach) for SSI-Funded Chronic Disease Patients |
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243 | (1) |
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243 | (1) |
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Cost-Structuring for Capitated Assumption of SSI Risk |
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243 | (2) |
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Positively Impacting Disease Adaptation |
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245 | (2) |
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Intended Outcomes of Innovative SSI Risk Approach |
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247 | (1) |
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247 | (2) |
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Chapter 10 Innovative MCO Financial Modeling for the 21st Century |
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249 | (18) |
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249 | (1) |
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Future Value of Managed Care Contracting: PART 1 |
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250 | (8) |
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Veracity of Charges in Managed Care Contracts |
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253 | (5) |
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Future Value of Managed Care Contracting: PART 2 |
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258 | (5) |
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The Elephant in the Room: How Health Plans Can Compete with State Health Exchanges |
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259 | (3) |
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Coming Clean about "Health Maintenance" |
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262 | (1) |
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Conclusion---A Final (?) Stroll Down Memory Lane |
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263 | (4) |
Index |
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267 | |