A Practical Guide to Reimbursement in Managed Care

by JoAnna B. Younts

This book provides a detailed historical account of Medicare reimbursement and payment approaches used across nearly all provider types, along with a practical discussion of commercial payer contracting and payment strategies. It then concludes with a deep dive into the legal issues that arise in payer-provider disputes, including the most common issues and case examples. A Practical Guide to Reimbursement in Managed Care provides historical background on Medicare reimbursement approaches as well as practical information on how commercial payers have adopted (or not adopted) Medicare reimbursement approaches and the challenges they have faced in the process -- both from a contracting strategy standpoint as well as a legal standpoint. Working through Medicare's reimbursement approaches across different types of healthcare providers, from hospitals to physicians and ancillary services, the book traces the origins of each of Medicare reimbursement systems and provides useful details on how the Medicare program calculates rates. It then moves into the commercial health insurance space, describing important concepts related to payer-provider contracting, types of health plans, and payer and provider perspectives on how they approach the contractual relationship. A Practical Guide to Reimbursement in Managed Care also provides a historical view of contracting both from a provider and payer perspective, layering in historical milestones with practical reasons why the U.S. system has become what it is today. It then concludes with a deep dive into the important legal issues that arise in payer-provider disputes, including contracts, commonly disputed issues and case examples.

202 pages, Paperback

Published January 30, 2024