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Managing Physical Rehabilitation
in a Managed Care Environment
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this product Online??
Authors
Peter R. Kovacek, MSA, PT
President, KovacekManagementServices, Inc
Harper Woods, Michigan
Kathleen A. Jakubiak Kovacek, PT
Administrator, Rehabilitation Services
Bon Secours Cottage Health System
Grosse Pointe Farms, Michigan
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Purchase Price: $49.95 + $6.05 S/H.
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KovacekManagementServices, Inc
(313) 884-8920
(313) 884-8510 fax
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20225 Danbury Lane
Harper Woods, MI 48225
Publication Date February 15, 1998
248 Pages - Binder bound, Illustrated.
Wanna Make Managed Care in Rehab
more Funner?
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Managed Care Game
Why an Entire Book on Managing Rehab in a Managed Care Environment?
The past few years have seen tremendous changes in health care delivery systems.
Many experts have attributed these changes to the growth of managed care. Although
not all areas of physical rehab are equally affected by managed care, no area of rehab is
immune from the effects of managed care. Throughout this book, we will attempt to
provide a balance view of managed care and the physical rehab industry. It is our
belief that managed care is not inherently harmful or immoral. We do, however,
strongly believe that the manner in which managers of rehab practices approach the unique
challenges and opportunities inherent in managed care will have a tremendous impact on the
success of those practices. Throughout this book, we will attempt to present
background information related to managed care and its impact on rehab practices. We
will, whenever possible, also try to identify the alternatives available to rehab
managers.
This book is designed to help you, the rehab manager, student or aspiring rehab
manager, succeed in a rapidly changing healthcare world. Although, at times, a
very complex and confusing area, managed care and reimbursement knowledge and skills are
very important to your success as a manager, leader and clinician.
Who is this Book Intended For?
This book is intended for rehab professionals, including physical therapists,
occupational therapists, speech-language pathologists, rehab nurses, physicians
specializing in physical medicine, and professionals without a clinical background who may
manage physical rehab programs. This book is also intended for students in any of
these areas.
Purpose
Our objectives in preparing this book are multiple. We hope that this book will
help you
1. Review the important concepts of managed care and reimbursement to help you in your
rehabilitation practice.
2. Explore your thoughts and feelings about various reimbursement strategies and
managed care in general.
3. Review incentives for specific clinical behaviors inherent in various reimbursement
and managed care models.
4. Identify optimal clinical and managerial behaviors for financial return and clinical
success.
5. Plan for future changes in your clinical behavior required by the continuously
changing healthcare environment.
6. Develop an action plan that will allow you to thrive in the healthcare future.
References
A complete set of references to the topic of managed care and rehabilitation is
included in the Appendix. Specific data referenced in the body of the book are from
US governmental sources unless otherwise indicated.
Using This Book
Because parts of this book, especially the first chapter and the case studies, are
formatted as a workbook, not all the answers will be given to you. You will need to
work to find your own answers for some items. Many of the concepts presented do not lend
themselves well to a singular best answer or strategy. In many cases, the best
option "depends" on many factors that may be relatively unique to your setting
and practice.
It is our hope that this combination of background information, review of implications
and structured learning will help you manage your staff and practice better and ultimately
promote success for your patients.
Your comments, criticisms and success stories are always welcome feedback. You may
contact us via email through the primary author at PKOVACEK@PTManager.com
.
Wanna Make Managed Care in Rehab
more Funner?
Click here for information on The
Managed Care Game
Details of the Contents
There are 8 Chapters in this book
1. Self Assessment - Checking your
readiness for managed care
2. Overview of managed care
3. Types of managed care
organizations
4. Reimbursement methodologies in
rehabilitation
5. Clinical Strategies in Rehabilitation
for Managed Care
6. Management strategies in
rehabilitation for managed care
7. The
Balanced Budget Act of 1997 - Impact on rehabilitation
8. Future trends in
rehabilitation and managed care
Appendix
- Glossary
- The Productivity Quiz
- Listing of State Insurance Offices
- References on managed care
- DRG Listing
- Action Planning Worksheet
Chapter 1 -Self
Assessment
- Defining Success
- Optimal Quality/Quantity/Reimbursement/Cost Containment
- Checking your Readiness for Change
- Personnel Issues
- Attitudes toward managed care, self-determination, productivity and
quality care
- Definitions of success, acceptable quantity and quality care
- Knowledge of managed care and reimbursement
- Non-hands-on clinical skills
- Case Management/ Delegation Skills/Negotiation Skills
- Time Management/Productivity/Patient Education
- Motivation to succeed in Managed Care
- Your Current Clinical Environment
- Payer Mix
- Managed Care Penetration
- Mix of Managed Care Penetration by Managed Care Organization type
- Managed Care Competition
- Past History of Managed Care
- Legislative Environment
- Industry Changes in Managed Care
- Business and Clinical Systems
- Clinical Care
- Previous Actions Taken to Address Managed Care
- Profile of Patient Care/Treatment Guidelines/Clinical Care Report Card
- Frequency and Dissemination of Data
- Systems in Place
- Financial Systems/Documentation Systems
- Patient Scheduling Systems/Productivity Management Systems
- Outcomes Management Systems/Quality Improvement Systems
- Third Party Relations
- Information Systems
- Data Collections
- Types of Data Collected and Analyzed
- Methods/Dissemination of Information
- Commitment to Improvement
Return to detailed contents overview.
Chapter 2
-Overview of Managed Care
- Where did Managed Care Come from?
- The Traditional Health Care System/Traditional Health Care Financing
- Purchasers of Health Care
- Government/Employers/Insurance Organizations/Purchasing Pools
- Sub Contracts
- What is Different in Managed Care?
- Defining Managed Care
- How Does Managed Care Work?
- Appealing a Decision by Managed Care Organizations
- What are the Advantages of Joining a Managed Care Plan?
- What are the Disadvantages of Joining a Managed Care Plan?
- Managed Care Financing
- Traditional Health Care Compared to Managed Care
- How Managed Care Pays Providers
- Sharing Financial Risk
- Capitation
- What is the future likely to bring in managed care?
Return to detailed contents overview.
Chapter
3 - Types of Managed Care Organizations
- Conventional Health Insurance /Health Maintenance Organizations
- Preferred Provider Organizations/Exclusive Provider Organizations
- Point of Service Plans
- Specialty Managed Care Organizations
- Physician Hospital Organizations and Provider Service Organizations
- Organizational Structures of Health Care Organizations
- Managed Care Organization Structure/Hospital Structure
- Hospital Medical Staff Structure/Medical Groups/IPA Structure
- Medicare
- Medicare Part A Coverage/Medicare Part B Coverage
- The Scope of Medicare Coverage
- Medicare Program Financing, Beneficiary Liabilities and Vendor Payments
- Medicare Claims Processing/ Managed Care in Medicare and Medicaid
- Peer Review Organizations/ Administration of Medicare
- Medicaid
- Medicaid Basis of Eligibility and Maintenance Assistance Status
- Scope of Medicaid Services/Amount and Duration of Medicaid Services
- Payment for Medicaid Services
- Federal Regulation of Governmental Managed Care Programs
- Federal Regulation of non Governmental Managed Care Programs
- State Regulation of Managed Care
- Implications of Managed Care Type for Rehabilitation Providers
Return to detailed contents overview.
Chapter 4 -
Reimbursement Methodologies in Physical Rehabilitation
- Mechanisms of Reimbursement
- Fee For Service/Fee Schedule/Out of Pocket
- Cost Reimbursement
- Cost reports/Tax Equity and Fiscal Responsibility Act (TEFRA)
- Prospective Payment
- Diagnosis Related Groupings (DRG)
- Case Rate (Case Capitation)
- Capitation/Full Risk Sharing
- Who are the Players?
- The Transactions
- HMO-Hospital Transactions/ PPO-Hospital Transactions
- IPA-Hospital Transactions/ HMO-IPA-PHO Transactions
- Risk as a currency
- Therapy Venues and Reimbursement Methodology
- Changing nature of reimbursement
- Reference to Futures and The Balanced Budget Act of 1997 Section
- Venues and Practice Settings for Rehabilitation Providers
- Acute inpatient care/Hospital-based ambulatory care
- Private Practice ambulatory care/Rehabilitation agency
- Comprehensive Outpatient Rehabilitation Facility (CORF)
- Community home care agency/Inpatient Medical Rehabilitation Programs
- Skilled Nursing Facility (SNF)/Sub Acute Rehabilitation
Return to detailed contents overview.
Chapter 5 -
Clinical Strategies in Physical Rehabilitation for Managed Care
- Clinical Management in Managed Care
- Market Response/Financial Response
- Provider Satisfaction/Member Satisfaction
- Data Needs/Clinical Management Components
- Resource Management
- Quality Management as a Component of Clinical Management
- Information Management/Resources Required for Clinical Management
- Case Management in Managed Care
- Organizational Use of Case Management/MCO Use of Case Management
- Case Management Program Characteristics/Organization
- Policies and Procedures of Case Management Programs
- Links of Case Management to Other Departments
- The Nature of Case Management
- Use of Case Management in Rehabilitation Practice
- Legal Implications of Case Management
- Development of Case Management Programs
- Clinician Buy-in for Case Management Programs
- Utilization Management in Managed Care
- Referral Management/Scope of Practice Management
- Referral Guidelines/Authorization/Service Authorization
- Outcomes Management in Managed Care
- Quality Management
- Definitions in Quality Management/ Quality Drivers in Managed Care
- Characteristics of Successful Quality Programs
- Credentialing in Managed Care
- Clinician Requirements/ Non-Physician and Provider Requirements
- The Credentialing Process
- Delegated Credentialing
- Accountability Management in Managed Care
- Accountability Framework/Accountability Mechanisms
- Provider Contracts/Accreditation
- Federal Accountability/State Accountability
- The Legal System/Marketplace Demands
- The Importance of Continuing Clinical Education in Managed Care
Return to detailed contents overview.
Chapter 6 -
Management Strategies for Rehabilitation in Managed Care
- Financial Strategies
- How to Negotiate a Managed Care Contract
- Managed Care Contracting
- Preparing for Managed Care Contracting
- Key Factors Before Negotiations Begin
- Getting Started
- Contract Review Check List
- Long Term Contracts
- Ending the Managed Care Organization Relationship
- What Happens After Termination?
- Additional Considerations in Contracting
- Does Contracting in a Managed Care Environment Really Change the Way in
Which Care in Delivered?
- How to Position Yourself Within Your Organization for Influence in
Managed Care Organization Decisions
- Who to Contract With
- So You're Interested in a Contract, Now What?
- Managing Capitation
- Flavors of Capitation
- Specialist Contracting
- Capitation - Not for the Timid
- Obtaining a Capitation Contract
- How a Rehabilitation Capitation is Developed
- Information Systems Needed for Effective Management of Managed Care
- Interactions with Managed Care Organizations
- Organizational Influence within a Managed Care Organization
- Implications of Managed Care Success for Rehabilitation Providers
Return to detailed contents overview.
Chapter 7 - The Balanced Budget Act of 1997
- Overview of The Balanced Budget Act of 1997
- The Rehabilitation Continuum Network
- Outpatient Rehabilitation Services
- Outpatient Physical Therapy Standards Act
- $1500.00 Cap
- Fee Schedule
- Impact of the Outpatient Rehabilitation Changes on the Balance of the
Rehabilitation Continuum
- Skilled Nursing Facilities
- Prospective Payment
- Transition Period
- Consolidated Billing
- Impact of the Home Health Rehabilitation Changes on the Balance of the
Rehabilitation Continuum
- Home Health Services
- Prospective Payment
- Interim Payments
- Modification of Part a for Individuals in Part B
- Impact of the Skilled Nursing Facility Rehabilitation Changes on the
Balance of the Rehabilitation Continuum
- Hospitals
- Payment for Hospital Outpatient Department Services
- Discharge Definition in Transferring to Post-acute Care
- Impact of the Hospital Rehabilitation Changes on the Balance of the
Rehabilitation Continuum
- PPS Exempt Units and Hospitals TEFRA Limits
- Prospective Payment for Inpatient Rehabilitation
- Impact of the Inpatient Rehabilitation Changes on the Balance of the
Rehabilitation Continuum
- Disclosure Changed in The Balanced Budget Act of 1997
- Overall Impact of The Balanced Budget Act of 1997 on the Balance of
the Rehabilitation Continuum
- RBRVS Single Conversion Factor
- Medicare + Choice
Return to detailed contents overview.
Chapter
8 - Future Trends in PM&R and Managed Care
- Uncertainty of the Future
- Risk Sharing
- Why risk sharing is attractive
- The problems with risk sharing
- Most likely risk sharing structures in the future
- Implications of risk sharing for rehabilitation providers
- Capitation
- Most likely capitation structures in the future
- Why capitation is attractive
- The problems with capitation
- Implications of capitation for rehabilitation providers
- Provider Networks
- Forms of provider networks
- Horizontal networks
- Vertical networks
- Most likely network structures in the future
- Why networks are attractive
- The problems with networks
- Implications of networks for rehabilitation providers
- Managing in the future
- The Adaptive Clinician
- Developing and managing the adaptive clinician
- The virtual organization
- Managing change
- Defining and measuring success
- Clinical
- Managerial
- Organizational
- Professional and personal rewards in the future
Return to detailed contents overview.
Wanna Make Managed Care in Rehab more
Funner?
Click here for information on The
Managed Care Game
KovacekManagementServices, Inc.
20225 Danbury Lane
Harper Woods, MI 48225
(313) 884-8920
(313) 884-8510 fax
Order
this product Online??
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Last modified: January 31, 2004