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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.
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New contributors
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New chapter on the Patient Protection and Affordable Care Act of March 2010
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New chapter on enrollment and billing
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New chapter on fraud and abuse
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Completely re-written chapter on information systems and electronic data interchange
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Completely re-written chapter on Medicaid Managed Health Care
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Complete restructuring of section 2 with a new focus on structure and payment across all types of health care delivery systems
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New chapter on physician practice behavior and managed health care
Introduction 1 Introduction
Part One Introduction to Health Insurance and Managed Health Care
Chapter 1 A History of Managed Health Care and Health Insurance in the United States By Pete Fox and Peter R. Kongstvedt
Chapter 2 Types of Health Insurers, Managed Health Care Organizations and Integrated Healthcare Delivery Systems By Eric Wagner and Peter R. Kongstvedt
Chapter 3 Elements of the Management and Governance Structure By Peter R. Kongstvedt
Part Two Network Contracting and Provider Payment
Chapter 4 The Provider Network By Peter R. Kongstvedt
Chapter 5 Provider Payment By Peter R. Kongstvedt
Chapter 6 Legal Issues in Provider Contracting By Mark S. Joffe and Kelli D. Back
Part Three Management of Utilization and Quality
Chapter 7 Basic Utilization and Case Management By Peter R. Kongstvedt
Chapter 8 Fundamentals and Core Competencies of Disease Management By David W. Plocher
Chapter 9 Physician Practice Behavior and Managed Health Care By Jay Want and Peter R. Kongstvedt
Chapter 10 Data Analysis and Provider Profiling in Health Plans By David W. Plocher & Nancy Garrett
Chapter 11 Prescription Drug Benefits in Managed Care By Robert P. Navarro, Craig Stern, and Rusty Hailey
Chapter 12 Introduction to Managed Behavioral Healthcare Organizations By Joann Albright, Deborah Heggie, Anthony M. Kotin, Connie Salgy, Wanda Sullivan, and Fred Waxenberg
Chapter 13 Disease Prevention in Managed Health Care Plans By Mark Manley
Chapter 14 Quality Management in Managed Health Care By Pamela B. Siren
Chapter 15 Accreditation and Performance Measurement Programs in Managed Health Care By Margaret E. O'Kane
Part Four Sales, Finance and Administration
Chapter 16 Marketing and Sales By Richard Birhanzel
Chapter 17 Enrollment and Billing By Karl V. Kovacs
Chapter 18 Claims and Benefits Administration By Donald L. Fowler, Jr. and Elizabeth Pascuzzi
Chapter 19 Health Care Fraud and Abuse By Christie Moon
Chapter 20 Member Services By Kevin Knarr and Peter R. Kongstvedt
Chapter 21 Operational Finance and Budgeting By Dale F. Cook and Christopher Campbell
Chapter 22 Underwriting and Rating By Michael G. Sturm and Troy M. Filipek
Chapter 23 Information Systems and Electronic Data Interchange in Managed Health Care By James S. Slubowski
Part Five Special Markets
Chapter 24 Health Plans and Medicare By John K. Gorman, Jean D. LeMasurier, William A. MacBain, Stephen J. Balcerzak, Wendy K. Burger and Amy Huang
Chapter 25 Medicaid Managed Health Care By Rodney C. Armstead, Catherine K. Anderson, Elizabeth Cabot Nash
Chapter 26 The Military Managed Care Health System By M. Nicholas Coppola, Ronald P. Hudak, Forest S. Kim, Lawrence Fulton, Jeffrey P. Harrison, and Bernie Kerr
Chapter 27 Managed Care in a Global Context By Jonathan P. Weiner, Emily Adrion, Joanna Case Famadas, Djordje Gikic and Hugh Waters
Part Six Laws and Regulations
Chapter 28 State Regulation of Managed Health Care By Tom Wilder
Chapter 29 Federal Regulation of Health Insurance and Managed Health Care By Tom Wilder
Chapter 30 The Patient Protection and Affordable Care Act By Tom Wilder
Peter R. Kongstvedt, MD
Dr. Peter Kongstvedt is an indepenent strategic advisor, and a Senior Health Policy Faculty member in the Department of Health Administration and Policy at George Mason University. He is a well known national authority on the health care industry with particular expertise in health insurance and managed health care, with over 30 years of industry experience as both a senior-level executive and with global consulting firms. Dr. Kongstvedt is also the author of Managed Care, What it Is and How it Works, (Jones & Bartlett), and recently created an online multimedia training program on health insurance and managed care. Prior to passage of health reform, he consulted to and made several appearances on The CBS Evening News, and also appeared on NBC’s Today Show.
He is principal of the P.R. Kongstvedt Company, LLC and Kongstvedt Learning Solutions, LLC in McLean, VA and may be reached through his website at www.Kongstvedt.com. Additional Titles by this Author
ISBN-13: 9781449653194