An insightful overview of health insurers and a guide to sustainability for provider organizations. Physicians experience ongoing frustrations in their relationships with health plans. Even as they struggle to keep up with accelerating clinical advances, they face daunting challenges from payers that are transitioning from traditional fee-for-service contracts to complex alternative payment models. In Health Plans Unmasked, Martin Lustick, MD, offers insights and guidance for those who face the herculean task of transforming their business practices to achieve financial stability while improving outcomes for their patients. By explaining both how and why insurance companies behave the way they do, Dr. Lustick helps providers avoid mistakes and take advantage of opportunities for success. He provides information on: * The evolution of health care financing in the United States * The nuts and bolts of health plan capabilities and the real motives of health plan administrators * Tips for successful contracting strategies * Alternative payment models and the promises of value-based care With a career spanning five decades as a practicing pediatrician, chief operating officer of a medical group, chief medical officer of a hospital, and chief medical officer of a health plan, Dr. Lustick provides a straightforward guide to sustainability for provider organizations. Physicians, office managers, and anyone in a health-related field will benefit from his breaking down the role of health plans in our health care ecosystem.
Martin Lustick, MD (CANANDAIGUA, NY), is a pediatrician. His career in medicine includes 20 years in clinical practice and leadership roles in a large physician group, a hospital, a nonprofit health plan, and a health care software company.
Foreword Acknowledgments Section 1: The Basics 1. Historical Context 2. What is a Health Plan? 3. Medicare 4. Medicaid 5. Commercial Insurance 6. Brokers and Consultants Section 2: Reimbursement Basics 7. The ABCs of Fee for Service 8. What Happens to a Claim? 9. Payment Errors 10. Health Plan Strategic Concerns 11. Analytics 12. Cost Management Strategies 13. Quality 14. Care Management 15. Health Plan Committees Section 3: Contracting 16. Health Plan Contracting 101 17. Value-Based Budgeting 18. Incentive Payments 19. Risk Mitigation Section 4: Opportunities and Obstacles in Value-Based Care 20. Price Transparency 21. Subrogation 22. Pharmacy Benefit Management 23. On Becoming a Payvider Section 5: A Shifting Paradigm 24. Closing Thoughts Glossary of Acronyms Index
An insightful overview of health insurers and a guide to sustainability for provider organizations.
