Managed Care 2007

Managed Care 2007 - Chapter Thirteen Managed Care Managed...

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Chapter Thirteen Managed Care
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Managed  Care no one definition or understanding; different segments of the health care     industry have different definitions; in general, it is a process of altering or  changing the  health care system  in the  form of  price, access, and/or quality.
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        Prospective  Pricing Capitation Bundling of Services Managed Mandatory Utilization Review Care Peer  Review Benefit Redesign Channeling Quality Criteria Health Promotion
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Managed Care  consists one or more of the  following fundamental components: 1)  Prospective Pricing 2)  Peer Review 3)  Channeling 4)  Quality Criteria 5)  Health Promotion     
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1. Prospective Pricing   is the setting or negotiation of prices  prior to (before) the delivery of the  health care services;   retrospective pricing (setting of prices  after delivery of service) used to be  the  predominant method in the health care  industry;    
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   Types of Prospective Pricing : c.  Capitation d.  Bundling
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    a percentage discount for services;  wide variations of discount due to     different contracts/agreement; an average dollar amount for services; given service area/location; wide variation in pricing;
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c.  Capitation Payment a fixed amount of money per month for  services regardless of frequency and type  little variation in pricing ($300/mth/pt);   d. Bundling of Services grouping of health products and services  board, Rx, lab tests, etc.); grouped into ‘$ per day’ or ‘$ per disease  state’; ex.  DRG;
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2.  Peer Review
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Managed Care 2007 - Chapter Thirteen Managed Care Managed...

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