Healthcare Law

Managed Care Law Manual is a unique legal guide specific to managed care filled with the facts health care attorneys, managed care organizations, and health care administrators need to make informed choices. This legal guide will help you know not only your legal obligations, but also those of your contracting partners, employers, third-party payers, physicians, and others so you can form the joint alliances that will be essential in the health care reform days ahead. This manual is always current with twice a year updates. Managed Care Law Manual has been updated to include: New information on CMS's proposed rule on the Medicare shared savings program for accountable care organizations Up-to-date material on civil monetary penalty sanctions under the Health Insurance Portability and Accountability Act Information on states that require coverage for autism treatment Updated material on states that require health plans to cover patient care costs in clinical trials Case law regarding unreasonable restraint of trade New material on state external review laws Recent ERISA case law addressing claims based on denial of coverage Seff v. Broward County, a recent case dealing with voluntary wellness programs and the Americans with Disabilities Act (ADA) New case law addressing false claims and credentialing Recent OIG advisory opinions regarding the Anti-Kickback statute Up-to-date material regarding state false claims acts Information on the recently released IRS/Treasury Priority Guidance Plan New CMS guidance regarding Medicare Advantage (MA) marketing and enrollment Recent case law regarding mental health coverage

Managed care and the litigation landscape; Common managed care disputes; ERISA litigation; State law challenges in managed care; Providers versus payors : common legal disputes in managed care; Providers versus payors : common legal disputes in managed care; Managed behavioral health care litigation; Federal health programs and managed care litigation; Litigation issues in antitrust and managed care; Managed care class actions; Pay for performance and other value-based reimbursement arrangements in health care: foundation, administrative structure, and legal pitfalls.

PLI's Health Care Litigation and Risk Management Answer Book 2015 is designed to provide health care industry leaders and attorneys with a comprehensive and easy-to-use reference guide to risk management and litigation in the health care sector. The book covers government regulation, including the False Claims Act, the Stark law, the Anti-Kickback Statute, and EMTALA, as well as major areas of private litigation risk, such as employment litigation and insurer/provider disputes. The book also provides discussion of compliance strategies to avoid investigations, fines, and litigation, and litigation strategies should the need arise. This Answer Book not only provides clear and concise information in a Q&A format, but also includes extensive appendices of reference material, such as key statutes, compliance guidance from the DOJ, FTC, and OIG, and a sample corporate integrity agreement.

Chapter 7 focuses on Managed Care Disputes and Litigation.

Within the international discussion on the structure of healthcare systems, managed care is an increasingly important topic. Over more than twenty years managed care approaches have fundamentally influenced healthcare systems in terms of patient orientation, efficiency, and quality. Experts assume that up to 20% of healthcare expenses can be saved by applying high-quality managed care approaches. By using suitable organisational forms and management principles, not only can costs be reduced, but the quality of medical service provision can be augmented. Managed care is therefore much more than a cost-cutting strategy. The goal of this book is to offer a systematic overview of the organisational forms and management instruments implemented in managed care. Advocates consider managed care to be a logical and necessary developmental step in modern healthcare systems. An increase in quality and at the same time a reduction of costs is not seen as contradictory but rather as consistent. Therefore, managed care is a response to changed challenges in the provision of healthcare.​

As the most widely-used textbook on managed care, Essentials of Managed Health Care, Fifth Edition, provides an authoritative and comprehensive overview of the key strategic, tactical, and operational aspects of managed health care and health insurance in the commercial sector, as well as Medicare, Medicaid, and military medical care. With learning objectives for each chapter, a glossary of terms and common acronyms, study questions, tables and charts, and the expert guidance of Peter R. Kongstvedt, Essentials of Managed Health Care, Fifth Edition, is the perfect introduction to the key concepts of managed care. This revision includes updates to all chapters, as well as: New chapters on disease management, case management, pharmacy benefits management, behavioral health management, prevention, and the use of data and analysis in care management. New chapters on claims administration, sales and marketing, healthcare consumerism, and the employer's view of managed health care. A completely revised chapter on the new Medicare/Medicaid laws and programs. New chapters on the military health system and managed care in a global context. A new chapter on HIPAA. Book jacket.

Chapter 26 focuses on Managed Care Organizations

Representing the combined work of more than forty leading compliance attorneys, Corporate Compliance Answer Book helps develop, implement, and enforce compliance programs that detect and prevent wrongdoing.

Use risk assessment to pinpoint and reduce your company’s areas of legal exposure; Apply gap analysis to detect and eliminate flaws in a compliance program; Conduct internal investigations that prevent legal problems from becoming major crises; Develop records management programs that prepare you for the e-discovery involved in investigations and litigation; Satisfy labor and employment mandates, environmental rules, lobbying and campaign finance laws, export control regulations, and FCPA anti-bribery standards
Make voluntary disclosures and cooperate with government agencies in ways that mitigate the legal, financial and reputational damages caused by violations; Featuring dozens of real-world case studies, charts, tables, compliance checklists, and best practice tips,

As a result of intense lobbying by consumers and health care providers, managed care organizations are under close scrutiny. More and more frequently, states are taking assertive roles in governing managed care operations, including monitoring how they contract with providers and what types of benefits they provide to enrollees. In this volume, you'll learn how MCOs nationwide are being held accountable to a complex array of new laws -- and what you can expect and demand from MCOs.