Acknowledgments |
|
xiii | |
About the Author |
|
xv | |
Introduction |
|
xvii | |
Section I Introduction to Provider Organizations |
|
|
Chapter 1 The Goals and Objectives of Physician Alignment and Integration: Form Follows Function |
|
|
3 | (8) |
|
Chapter 2 Independent Practice Associations (IPAs) |
|
|
11 | (20) |
|
|
17 | (2) |
|
|
18 | (1) |
|
|
19 | (1) |
|
|
19 | (1) |
|
|
19 | (1) |
|
Financing and Managing the IPA |
|
|
19 | (2) |
|
|
21 | (1) |
|
Operations Management for the IPA |
|
|
21 | (10) |
|
Administrative Staffing for the IPA |
|
|
22 | (1) |
|
Governance Issues for the IPA |
|
|
22 | (1) |
|
|
22 | (2) |
|
|
24 | (2) |
|
|
25 | (1) |
|
|
25 | (1) |
|
|
25 | (1) |
|
Utilization Management Committee |
|
|
25 | (1) |
|
Quality Assurance (QA) Committee |
|
|
26 | (1) |
|
|
27 | (1) |
|
|
27 | (1) |
|
Other Concerns Relevant to Prequalification for Membership |
|
|
28 | (1) |
|
|
28 | (35) |
|
|
28 | (1) |
|
Recertification and Recredentialing |
|
|
28 | (1) |
|
|
28 | (1) |
|
|
29 | (2) |
|
Chapter 3 Physician Hospital Organizations (PHOs) |
|
|
31 | (14) |
|
|
32 | (1) |
|
|
32 | (1) |
|
Negotiation and Projection Hindrances |
|
|
33 | (1) |
|
Differences in Administrative Style among Members |
|
|
33 | (2) |
|
Managed Care Contracting with Payors |
|
|
35 | (1) |
|
Governance Issues: Control |
|
|
35 | (1) |
|
Medicare Anti-Kickback and Practice Acquisitions |
|
|
36 | (9) |
|
Chapter 4 Accountable Care Organizations (ACOs) |
|
|
45 | (10) |
|
Chapter 5 Management Services Organizations (MSOs) |
|
|
55 | (8) |
|
Three Basic Elements of MSOs |
|
|
55 | (8) |
Section II Integrated Health Delivery System Development |
|
|
Chapter 6 Corporate Form: Myriad Choices |
|
|
63 | (10) |
|
|
63 | (1) |
|
Disadvantages of General Partnerships |
|
|
63 | (1) |
|
|
64 | (2) |
|
Advantages of Limited Partnerships |
|
|
64 | (1) |
|
Disadvantages of Limited Partnerships |
|
|
65 | (1) |
|
|
66 | (2) |
|
Advantages of Corporations |
|
|
66 | (2) |
|
Disadvantages of Corporations |
|
|
68 | (1) |
|
The Subchapter S Corporation |
|
|
68 | (2) |
|
Disadvantages of S Corporations |
|
|
69 | (1) |
|
Double-Taxation Considerations |
|
|
70 | (1) |
|
The Limited Liability Corporation (LLC) |
|
|
70 | (3) |
|
Chapter 7 The Steering Committee Gets Busy: Step-by-Step Instructions for What to Do and How to Do It |
|
|
73 | (10) |
|
Steering Committee Task List |
|
|
73 | (6) |
|
Background/Understanding of Task |
|
|
73 | (2) |
|
Develop a Statement of the Committee's Purpose |
|
|
73 | (1) |
|
|
74 | (1) |
|
Development of the Shared Vision |
|
|
75 | (1) |
|
Organizational Development of the IPA |
|
|
75 | (2) |
|
Organizational Development of the MSO Required of the Steering Committee |
|
|
77 | (1) |
|
|
78 | (1) |
|
Development of a Business Plan |
|
|
78 | (1) |
|
Organizing the Steering Committee |
|
|
79 | (4) |
|
Multi-Specialty IPA or PHO |
|
|
79 | (1) |
|
Single-Specialty IPA or PHO |
|
|
80 | (1) |
|
Management Services Organization (MSO) |
|
|
81 | (1) |
|
Other Concerns of the Steering Committee |
|
|
81 | (2) |
|
Chapter 8 Guidance for the Utilization Management and Quality Improvement Steering Committees |
|
|
83 | (8) |
|
|
84 | (7) |
|
Utilization Management Program Outline |
|
|
84 | (1) |
|
Quality Improvement and Assurance Program |
|
|
85 | (1) |
|
Activities to Study and Frequency of Each Study |
|
|
86 | (1) |
|
Frequently Asked Questions by the Health Plans (Don't Be Caught Without An Answer!) |
|
|
86 | (1) |
|
|
87 | (1) |
|
|
88 | (3) |
|
Chapter 9 Network Financial Management: The Intersection of Finance, Utilization Management and Capitated Risk Management |
|
|
91 | (6) |
|
|
92 | (1) |
|
Utilization Management Reports |
|
|
92 | (3) |
|
Additional Monitoring Reports |
|
|
95 | (2) |
|
Chapter 10 Provider Organization Credentialing and Privileging |
|
|
97 | (10) |
|
Typical Managed-Care Provider Organization Representations and Warranties |
|
|
97 | (2) |
|
|
99 | (1) |
|
Practitioner Requirements |
|
|
99 | (1) |
|
Non-Physician and Provider Requirements |
|
|
100 | (1) |
|
|
101 | (3) |
|
|
104 | (1) |
|
|
105 | (2) |
|
Chapter 11 Credentialing Committee's Assignment: What to Do and How to Do It |
|
|
107 | (10) |
|
Due Diligence in Credentialing |
|
|
108 | (3) |
|
|
109 | (1) |
|
Master and Servant Liability |
|
|
109 | (1) |
|
|
110 | (1) |
|
Structuring a Good Credentialing Policy |
|
|
111 | (1) |
|
Provider Application for Credentialing |
|
|
112 | (5) |
|
|
112 | (1) |
|
Licensing/Certifications/Registration Numbers |
|
|
113 | (1) |
|
|
113 | (1) |
|
Professional Liability Coverage (at the time this application is completed) |
|
|
114 | (1) |
|
|
114 | (1) |
|
|
114 | (1) |
|
|
114 | (3) |
|
Chapter 12 Antitrust Compliance Task Force: Understanding Antitrust Concerns for Provider Networks |
|
|
117 | (20) |
|
What Are the Antitrust Laws' |
|
|
118 | (1) |
|
Terms Used in the Guidelines |
|
|
118 | (3) |
|
Federal Guidelines of Antitrust Enforcement Policy in Healthcare |
|
|
121 | (4) |
|
Statement 4: Providers' Collective Provision of Non-Fee-Related Information to Purchasers of Healthcare Services |
|
|
122 | (1) |
|
Statement 5: Providers' Collective Provision of Fee-Related Information to Purchasers of Healthcare Services |
|
|
122 | (1) |
|
Statement 6: Provider Participation in Exchanges of Price and Cost Information |
|
|
123 | (1) |
|
Statement 7: Joint Purchasing Arrangements among Healthcare Providers |
|
|
124 | (1) |
|
Statement 8: Physician Network Joint Ventures |
|
|
125 | (1) |
|
Use of the Messenger Model to Negotiate an Agreement with a Payor |
|
|
125 | (1) |
|
Characteristics of the Arrangement |
|
|
125 | (1) |
|
Legality of the Arrangement |
|
|
126 | (1) |
|
Variations on the Messenger Model |
|
|
126 | (1) |
|
Non-Integrated Network that Presents and Discusses Non-Fee Related Information and Uses the Messenger Model for Financial Arrangements |
|
|
127 | (3) |
|
|
127 | (3) |
|
|
129 | (1) |
|
Variation on the Arrangement |
|
|
129 | (1) |
|
|
129 | (1) |
|
Variation on the Arrangement |
|
|
129 | (1) |
|
|
129 | (1) |
|
Qualified Managed Care Plans (QMCPs) |
|
|
130 | (7) |
|
How the QMCP Concept Came About |
|
|
130 | (2) |
|
Substantial Financial Risk Must Be Shared |
|
|
132 | (1) |
|
Agency Analysis of Physician Network Joint Ventures that Fall Outside These Antitrust "Safety Zones" |
|
|
132 | (1) |
|
Statement 9: Multi-Provider Networks |
|
|
133 | (1) |
|
Shared Substantial Financial Risk |
|
|
133 | (1) |
|
No Sharing of Financial Risk |
|
|
134 | (1) |
|
|
134 | (1) |
|
|
134 | (1) |
|
|
135 | (1) |
|
Useful Addresses and Telephone Numbers |
|
|
135 | (2) |
|
Chapter 13 Business Plan Development |
|
|
137 | (12) |
|
|
139 | (7) |
|
|
139 | (4) |
|
|
139 | (1) |
|
|
140 | (1) |
|
|
140 | (1) |
|
|
140 | (1) |
|
|
140 | (1) |
|
|
141 | (1) |
|
|
141 | (1) |
|
|
141 | (1) |
|
|
141 | (1) |
|
|
142 | (1) |
|
|
142 | (1) |
|
|
142 | (1) |
|
Advertising and Promotion |
|
|
142 | (1) |
|
|
143 | (1) |
|
|
143 | (3) |
|
|
143 | (1) |
|
|
143 | (1) |
|
|
143 | (1) |
|
|
144 | (1) |
|
|
144 | (1) |
|
|
144 | (1) |
|
|
145 | (1) |
|
|
145 | (1) |
|
|
145 | (1) |
|
|
145 | (1) |
|
|
145 | (1) |
|
|
146 | (1) |
|
Keeping Your Infant Business Competitive: Nondisclosure Agreements |
|
|
146 | (25) |
|
Sample Nondisclosure Agreement |
|
|
146 | (3) |
|
Chapter 14 Guidance for the IT Committee |
|
|
149 | (10) |
Section III Business Development: Contracting and Marketing |
|
|
Chapter 15 Contracting with Payer Organizations |
|
|
159 | (12) |
|
Chapter 16 Contracting for Capitation and Bundled Service Arrangements |
|
|
171 | (12) |
|
|
171 | (2) |
|
Capitation Demographics Analysis |
|
|
171 | (1) |
|
|
172 | (1) |
|
Dealing with Unpredictable and Unmanageable Risk Reinsurance |
|
|
173 | (1) |
|
|
173 | (2) |
|
|
175 | (1) |
|
|
176 | (11) |
|
|
180 | (3) |
|
Chapter 17 Understanding Capitation Performance Guarantees |
|
|
183 | (4) |
|
Chapter 18 Considerations for Reinsurance Purchases for the Integrated Health Delivery System |
|
|
187 | (8) |
|
|
188 | (1) |
|
|
188 | (5) |
|
What to Consider when Buying Capitated Stop Loss/Reinsurance from a Private Insurer |
|
|
190 | (2) |
|
What to Consider when Buying Coverage from an Insurance Company |
|
|
192 | (1) |
|
Dealing with Managing General Underwriters (MGUs) |
|
|
193 | (2) |
|
What to Consider when Purchasing from a Managing General Underwriter |
|
|
193 | (2) |
|
Chapter 19 Opportunities in Delegated Utilization Management and Claims Management for the MSO |
|
|
195 | (4) |
|
Claims Payment Responsibilities (Delegated Claims Payment) |
|
|
195 | (1) |
|
Utilization Management (Delegation of Utilization Management) |
|
|
196 | (3) |
|
Chapter 20 Beyond Traditional HMO and PPO Contracts: Direct Contracting with Employer-Sponsored Health Benefit ERISA Plans |
|
|
199 | (12) |
|
More ERISA Plans than NCQA-Accredited HMOs and PPOs |
|
|
200 | (4) |
|
Demystifying Covered and Non-Covered Services |
|
|
200 | (4) |
|
Wrap SPD Document Requirements |
|
|
204 | |
Section IV Appendices |
|
|
Appendix A: Volunteer Committee Survey Form |
|
|
211 | (2) |
|
Appendix B: Sample LLC Document Set |
|
|
213 | (6) |
|
Appendix C: How to Hire the Right Consultants |
|
|
219 | (12) |
Index |
|
231 | |