Nelson Higher Education

Higher Education

Health Insurance and Managed Care: What They Are and How They Work, 5th Edition

  • Peter R. Kongstvedt
  • ISBN-10: 128415209X
  • ISBN-13: 9781284152098
  • 0 Pages | Paperback
  • COPYRIGHT: 2020 Published
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About the Product

Health Insurance and Managed Care: What They Are and How They Work is a concise introduction to the foundations of the American managed health care system. Written in clear and accessible language, this handy guide offers an historical overview of managed care and then walks the reader through the organizational structures, concepts, and practices of the managed care industry. The Fifth Edition is a thorough update that addresses the current status of the Affordable Care Act including political pressures that have been partially successful in implementing changes. This new edition also explores the changes in provider payment models and medical management methodologies that can affect managed care plans and health insurers in many ways. The Fifth Edition also offers new or expanded coverage of: • The history of health insurance and managed care; • Instability in the public exchange marketing and sales channels; • The impact of limitations on sales, governance and administrative (SG&A) costs and profits; • Continued changes in Accountable Care Organizations (ACOs); • Continued changes in payment mechanisms such as value-based payment under the Medicare Improvement for Patients and Providers Act (MIPPA); • Continued consolidation of the health sector market place; • Continued pricing increases by providers and manufacturers; and more.

Table of Contents

Chapter 1: A History of Managed Health Care and Health Insurance in the United States
Chapter 2: Health Benefits Coverage, and Types of Health Plans and Payers
Chapter 3: The Provider Network
Chapter 4: Provider Payment
Chapter 5: Utilization Management, Quality Management, and Accreditation
Chapter 6: Sales, Governance, and Administration
Chapter 7: Medicare Advantage and Medicaid Managed Care
Chapter 8: Laws and Regulations in Health Insurance and Managed Care