Assignment: fraud control in the health care industry

Assignment: fraud control in the health care industry ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Assignment: fraud control in the health care industry I need an explanation for this Health & Medical question to help me study. Assignment: fraud control in the health care industry Examine Table 19-2 in your textbook and review the statutes, regulatory agencies, and organizations relevant to healthcare fraud (such as the Fraud Enforcement Recovery Act of 2009 [FERA] and the Patient Protection and Affordable Care Act [ACA]). Choose the initiative/organization that you believe has had the biggest impact on healthcare fraud control and write a paper discussing its impact. Consider the following questions: Does this statute/organization prevent or detect fraud? What type of fraud does it prevent/detect? How does it meet the challenges of fraud detection and prevention? Your paper should be 3 to 5 pages in length (not including the title and reference pages), double-spaced, and in conformance with the CSU-Global Guide to Writing and APA Requirements , and it must include a minimum of three additional sources. Assignment: fraud control in the health care industry iii._apa_template_paper.docx a126475_9781449653316.pdf Curriculum Development 1 Title of Paper Student’s Name Course Number (ORG500) – Name of Course (Foundations of Effective Management) Colorado State University – Global Campus Instructor’s Name August 6, 2010 Assessment 2 Title of Paper This is your introduction. If you need help writing this paper you can view the Writing an Effective Paper handout/tutorial which is located in the Library under the Library Tutorials. Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ulta ceet dolore magna si napi. Wisi e nim admin im veniam, quis nostrud. In atsvulpate velt esse meleste at semper manet sola. Ut lacreet dolore magna aliquam sic semper fi tyrannis erat volutpat. Wisi enim ad minim veniam. Dolore eu sata sfeugiat. Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ultaceet dolore magna si napi. Wisi e nim ad minim veniam, quis nos In a tsvulpate velt esse meleste at semper manet sola. UT lacreet dolore magna aliquam sic semp fi tyrannis erat volutpat. Wisi enim ad minim veniam. Dolore eu sata sfeugiat. Level 1 Header (Example: Leadership and Diversity) The Level 1 Header is going to be a broad topic. The Level 2 Header is a subtopic under Level 1 and Level 3 Headers is a subtopic under Level 2 Header, and so on. Depending on your topic and your outline, you may not use all the Headers. Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ulta ceet dolore magna si napi. Wisi e nim admin im veniam, quis nostrud. In atsvulpate velt esse meleste at semper manet sola. Ut lacreet dolore magna aliquam sic semper fi tyrannis erat volutpat. Wisi enim ad minim veniam. Dolore eu sata sfeugiat. Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ultaceet dolore magna si napi. Wisi e nim ad minim veniam, quis nos In a tsvulpate velt esse meleste at semper manet sola. UT lacreet dolore magna aliquam sic semp fi tyrannis erat volutpat. Wisi enim ad minim veniam. Dolore eu sata sfeugiat. Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ulta ceet dolore magna si napi. Wisi e nim admin im veniam, quis nostrud. In atsvulpate velt esse meleste Assessment 3 at semper manet sola. Ut lacreet dolore magna aliquam sic semper fi tyrannis erat volutpat. Wisi enim ad minim veniam. Dolore eu sata sfeugiat. Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ultaceet dolore magna si napi. Wisi e nim ad minim Level 2 Header – This is a subtopic of Level 1 (Example: Leadership) Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ulta ceet dolore magna si napi. Wisi e nim admin im veniam, quis nostrud. In atsvulpate velt esse meleste at semper manet sola. Assignment: fraud control in the health care industry Ut lacreet dolore magna aliquam sic semper fi tyrannis erat volutpat. Wisi enim ad minim veniam. Dolore eu sata sfeugiat. Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ultaceet dolore magna si napi. Wisi e nim ad minim veniam, quis nos In a tsvulpate velt esse meleste at semper manet sola. UT lacreet dolore magna aliquam sic semp fi tyrannis erat volutpat. Wisi enim ad minim veniam. Dolore eu sata sfeugiat. Level 3 Header – Indented, boldface, lowercase heading with a period. Begin body text after the period. This is a subtopic of Level 2 (Example: Team communication.). Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ulta ceet dolore magna si napi. Wisi e nim admin im veniam, quis nostrud. In atsvulpate velt esse meleste at semper manet sola. Ut lacreet dolore magna aliquam sic semper fi tyrannis erat volutpat. Wisi enim ad minim veniam. Dolore eu sata sfeugiat. Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Level 4 Header – Indented, boldface, italicized, lowercase heading with a period. Begin body text after the period. This is a subtopic of Level 3 (Example: Public speaking.). Ultaceet dolore magna si napi. Wisi e nim ad minim. Ulta ceet dolore magna si napi. Wisi e nim admin im veniam, quis nostrud. In atsvulpate velt esse meleste at semper manet sola. Ut lacreet dolore magna aliquam sic semper fi tyrannis erat volutpat. Wisi enim ad minim veniam. Dolore eu sata Assessment 4 sfeugiat. Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ultaceet dolore magna si napi. Wisi e nim ad minim Level 5 – Indented, italicized, lowercase heading with a period. Begin body text after the period. This is a subtopic of Level 4 (Example: Posture and tone.). Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ulta ceet dolore magna si napi. Wisi e nim admin im veniam, quis nostrud. In atsvulpate velt esse meleste at semper manet sola. Ut lacreet dolore magna aliquam sic semper fi tyrannis erat volutpat. Wisi enim ad minim veniam. Dolore eu sata sfeugiat. Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ultaceet dolore magna si napi. Wisi e nim ad minim veniam, quis nos In a tsvulpate velt esse meleste at semper manet sola. UT lacreet dolore magna aliquam sic semp fi tyrannis erat volutpat. Wisi enim ad minim veniam. Dolore eu sata sfeugiat. Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ulta ceet dolore magna si napi. Wisi e nim admin im veniam, quis nostrud. In atsvulpate velt esse meleste at semper manet sola. Ut lacreet dolore magna aliquam sic semper fi tyrannis erat volutpat. Wisi enim ad minim veniam. Dolore eu sata sfeugiat.Assignment: fraud control in the health care industry Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ultaceet dolore magna si napi. Wisi e nim ad minim Level 2 Header (Example: Diversity) Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ulta ceet dolore magna si napi. Wisi e nim admin im veniam, quis nostrud. In atsvulpate velt esse meleste at semper manet sola. Ut lacreet dolore magna aliquam sic semper fi tyrannis erat volutpat. Wisi enim ad minim veniam. Dolore eu sata sfeugiat. Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ultaceet dolore magna si napi. Wisi e nim ad minim Assessment 5 veniam, quis nos In a tsvulpate velt esse meleste at semper manet sola. UT lacreet dolore magna aliquam sic semp fi tyrannis erat volutpat. Wisi enim ad minim veniam. Dolore eu sata sfeugiat. Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ulta ceet dolore magna si napi. Wisi e nim admin im veniam, quis nostrud. In atsvulpate velt esse meleste at semper manet sola. Ut lacreet dolore magna aliquam sic semper fi tyrannis erat volutpat. Wisi enim ad minim veniam. Dolore eu sata sfeugiat. Ipsum lorem vei illum sat dolor euis mod tincidunt vei auminiure dolor in esse. Ultaceet dolore magna si napi. Wisi e nim ad minim Assessment 6 References Carroll, A. B. (1979). A three-dimensional conceptual model of corporate performance. The Academy of Management Review, 4(4), 497. [This is a journal article citation. Articles from the Library databases are based on print journals so the citation will end with page numbers.] Collins, J. (2001). Good to great. New York, NY: HarperCollins Publishers Inc. [This is a book citation.] Epstein, M. J. (2008). Making sustainability work. San Francisco, CA: Greenleaf Publishing Limited. Epstein, M., & Roy, M. (2003). Improving sustainability performance: Specifying, implementing and measuring key principles. Journal of General Management, 29(1), 15-31. French, S. (2009). Critiquing the language of strategic management. The Journal of Management Development, 28(1), 6-17. doi: 10.1108/02621710910923836 [This is a journal article citation from a Library database. Include a doi number if available.] Ginter, P., Ruck, A., & Duncan, W. (1985). Planners’ perceptions of the strategic management process. Journal of Management Studies, 22(6), 581-596. Hollingworth, M. (2009, November/December). Building 360 organizational sustainability. Ivey Business Journal Online. Retrieved from http://www.iveybusinessjournal.com/article.asp?intArticle_ID=868 [This is a journal that is published online, so you would include the URL.] Reuters. (2010). Walgreens Co. (WAG.N). Retrieved from http://www.reuters.com/finance/stocks/companyProfile?symbol=WAG.N Assessment 7 Walgreens. (2010a). Mission statement. Retrieved from http://news.walgreens.com/article_display.cfm?article_id=1042 [This is a website citation with a corporate author. If you retrieve information from various pages of this particular website, you need to cite each web page. However, because the author and the year will be exactly the same, the lowercase letters, “a,” “b,” etc. need to be added to the year. Assignment: fraud control in the health care industry The in-text citation would be: (Walgreens, 2010a).] Walgreens. (2010b). Our past. Retrieved from http://www.walgreens.com/marketing/about/history/default.html 2 World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 [email protected] www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to [email protected]. Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. This publication is designed to provide accurate and authoritative information in regard to the Subject Matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the service of a competent professional person should be sought. Essentials of Managed Health Care is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product. Some images in this book feature models. These models do not necessarily endorse, represent, or participate in the activities represented in the images. Production Credits Publisher: Michael Brown Managing Editor: Maro Gartside Editorial Assistant: Kayla Dos Santos Editorial Assistant: Chloe Falivene Production Assistant: Rebekah Linga Senior Marketing Manager: Sophie Fleck Teague Manufacturing and Inventory Control Supervisor: Amy Bacus Composition: Laserwords Private Limited, Chennai, India Cover Design: Kristin E. Parker Cover Image: © Barauskaite/ShutterStock, Inc. Printing and Binding: Courier Kendallville Cover Printing: Courier Kendallville To order this product, use ISBN: 978-1-4496-5331-6 Library of Congress Cataloging-in-Publication Data Essentials of managed health care / [edited by] Peter R. Kongstvedt.—6th ed. p. ; cm. Rev. ed. of: Essentials of managed health care / edited by Peter R. Kongstvedt. 5th ed. c2007. Includes bibliographical references and index. 3 ISBN-13: 978-1-4496-0464-6 (pbk.) ISBN-10: 1-4496-0464-1 (pbk.) I. Kongstvedt, Peter R. (Peter Reid) II. Essentials of managed health care. [DNLM: 1. Managed Care Programs—organization & administration—United States. 2. Delivery of Health Care—economics—United States. W 130 AA1] 362.1´04258—dc23 2011044614 6048 Printed in the United States of America 16 15 14 13 12 10 9 8 7 6 5 4 3 2 1 4 Contents Introduction Preface: Is Health Insurance? About the Author Contributors Part I Introduction to Health Insurance and Managed Health Care 1 1 A History of Managed Health Care and Health Insurance in the United States Peter D. Fox Peter R. Kongstvedt Introduction 1910 to the Mid-1940s: The Early Years The Mid-1940S to Mid-1960S: The Expansion of Health Benefits The Mid-1960S to the Mid-1970S: The Onset of Health Care Cost Inflation The Mid-1970S to Mid-1980S: The Rise of Managed Care The Mid-1980S to 2000: Growth, Consolidation, Maturation, and Backlash 2000 to 2010: Costs Rise and Coverage Declines Conclusion 2 Types of Health Insurers, Managed Health Care Organizations, and Integrated Health Care Delivery Systems Eric R. Assignment: fraud control in the health care industry Wagner Peter R. Kongstvedt Introduction Taxonomy Insured versus Self-Funded Benefits Plans The Managed Care Continuum Types of Health Insurers and Managed Care Organizations 5 Integrated Health Care Delivery Systems Organizations Emerging Under Health Reform Vertical Integration Conclusion 3 Elements of the Management and Governance Structure Peter R. Kongstvedt Introduction Board of Directors Key Management Positions Medical Management Committees Conclusion Part II Network Contracting and Provider Payment 4 The Provider Network Peter R. Kongstvedt Introduction Why Contract? The Service Area The National Provider Identifier Contract Management Physicians and Other Professionals The Data Bank On-Site Office Evaluation Medical Record Review Hospitals and Ambulatory Facilities Ancillary Services Conclusion 5 Provider Payment Peter R. Kongstvedt 6 Introduction It Is Payment, Not Reimbursement The Impact of Payment Methodologies Heterogeneity Is the Norm Payment of Physicians Payment of Hospitals, Health Systems, and Ambulatory Facilities Payment for Ambulatory Facility Services Combined Payment of Hospitals and Physicians Pay for Performance Payment for Ancillary Services Other New Models of Payment Under the Patient Protection and Affordable Care Act Conclusion Appendix 5-1: Examples of Research on the Impact of Managed Care or Capitation on Quality or Outcomes 6 Legal Issues in Provider Contracting Mark S. Joffe Kelli D. Back Introduction General Issues in Contracting Contract Structure Common Clauses, Provisions, and Key Factors Provider Obligations Payment Hold Harmless and No Balance Billing Clauses Relationship of the Parties Use of Name and Proprietary Information Notification Insurance and Indemnification 7 Term, Suspension, and Termination “Flow Down” Clauses and Provider Subcontracts Declarations Closing Conclusion Appendices Appendix 6-1: Sample Physician Agreement Appendix 6-2: Attachment B Compensation Schedule Appendix 6-3: Attachment B (Alternate) Capitation Payment Appendix 6-4: Sample Hospital Agreement Appendix 6-5: Sample Business Associate Addendum Part III Management of Utilization and Quality 7 Basic Utilization and Case Management Peter R. Kongstvedt Introduction Measurements and Metrics in Utilization Management Regional Variations in Utilization and Costs Benefits Design and Medical Utilization Demand Management Categories of Utilization Management Determination of Coverage, Medical Necessity, and Evidence-Based Clinical Guidelines Authorization and Precertification Managing Utilization of Physician Services Managing Utilization of Facility-Based Services Management of Complex Chronic Conditions Retrospective Review Routine Ancillary Services The Potential Impact of the ACA on Utilization Management Conclusion 8 8 Fundamentals and Core Competencies of Disease Management David W. Plocher Introduction Chronic Conditions Definition of Disease Management Disease Management Companies Components Common to Most Programs Measuring Effectiveness Challenges Using Current Engagement Model Health Plan Decision to Build versus Buy Outsourcing Contract Financial Risks Links to Other Health Care Programs International Disease Management Potential Future Applications of Disease Management Conclusion 9 Physician Practice Behavior and Managed Health Care 9 Jay Want Peter R. Kongstvedt Introduction General Aspects of Physician Practice Behavior How Physicians Are Responding to these Factors What We Should Do Instead: Several Principles Tools for Changing Physician Behavior Financial Incentives Programmatic Approaches to Changing Physician Behavior Addressing Noncompliance by Individual Physicians Conclusion 10 Data Analysis and Provider Profiling in Health Plans David W. Plocher 10 Nancy Garrett Introduction Data Sources Validity and Reliability Use of Claims Data for Analysis and Reporting The Need to Adjust for Risk Patient Data Confidentiality Employer Reporting and Analysis Provider Profiling Desired Characteristics of Provider Profiles Location of Profiling Activity Impact of ICD-10 Conclusion 11 Prescription Drug Benefits in Managed Care Robert P. Navarro Craig S. Stern 11 Rusty Hailey Introduction Prescription Drug Cost and Utilization Trends Future Trends Affecting Pharmacy Program Management Business Relationships and the Flow of Money Pharmacy Benefit Managers Prescription Drug Program Management Components Pharmacy Benefit Design Evidence of Coverage Health Information Systems and Claims Processing Electronic Prescribing Pharmacy Distribution Network Developing an Outpatient Pharmacy Provider Network Pharmacy/.Assignment: fraud control in the health care industry Provider Contracts and Claims Adjudication Pharmaceutical Contracting Drug Formulary Management Mail Service Pharmacy Specialty Pharmacy Distribution Clinical Pharmacy Programs Medicare and Medicaid Pharmacy Benefits Measuring Financial Performance Pharmacy Benefit Quality Measures and Patient Satisfaction Pharmacogenomics Conclusion 12 Introduction to Managed Behavioral Health Care Organizations 12 Joann Albright 13 Deborah Heggie Anthony M. Kotin 14 Connie Salgy 15 Wanda Sullivan 16 Fred Waxenberg Introduction: The Nature and Uniqueness of Behavioral Health Legislation Affecting Management of Behavioral Health Care The Public Sector Networks Payment Mechanisms New Types of Service Delivery Systems Behavioral Health Care Professional Providers Types of Services Delivered by Behavioral Networks Networks in the Public Sector Quality Management of Networks Use of Standardized Assessment Tools Utilization Management Outpatient Management Management of Inpatient and Intermediate Levels of Care Recent Trends in Utilization Management Recovery and Resiliency Specialized Services Telemental Health Services Intensive Care Management Quality of Care Accreditation In-House versus Outsourced Management of Behavioral Health Services Conclusion 13 Disease Prevention in Managed Health Care Plans 17 Marc Manely Introduction The Case for Prevention: A Cost-Effective Solution for Saving Lives A Complete Prevention Program Member Benefits Services for Members Contracting with Health Care Providers Public Policies Prevention and Health Care Reform Conclusion 14 Quality Management in Managed Health Care Pamela B. Siren Introduction Foundations of Reform: Premise for Quality Management Historical Perspective: The Evolution Traditional Quality Assurance Building on Tradition: Additional Components Continuous Improvement Process Model Value-Based Purchasing Conclusion 15 Accreditation and Performance Measurement Programs in Managed Health Care Margaret E. O’Kane Introduction Oversight by Type of Organization National Committee for Quality Assurance URAC 18 Accreditation Association for Ambulatory Health Care Conclusion Part IV Sales, Finance, and Administration 16 Marketing and Sales 19 Richard Birhanzel Introduction Defining the Managed Health Care Marketplace Health Plan Marketing Fundamentals Challenges to Effective Health Plan Marketing High Performance in Health Plan Marketing Practices Benefits Design Sales Conclusion 17 Enrollment and Billing Karl V. Kovacs 20 Scott McDaniel Peter R. Kongstvedt Introduction The Commercial Market Se … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10