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 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
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