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米国医療法律家協会編:医療保険契約ハンドブック 第7版

Health Plans Contracting Handbook: A Guide For Payors And Providers, 7th Edition

Cynthia F. Reaves, Esquire, Editor Robert M. Keenan III, Esquire

1 vol. Paperbound with CD-Rom. 2015年10月刊

American Health Lawyers Association (AHLA). ISBN: 9781632806147

¥35,541

在庫あり

管理医療契約の交渉準備、作成、実施、終了に至るまでのプロセスを順を追って解説。典型的な疑問点や情勢的な課題、医療制度改革が医療提供者と費用支払者の関係に与える影響などを取り上げています。有用な刊行物およびウェブ情報のリストと重要な検討事項のチェックリストを各章に備え、サンプル条項の全文が附属のCD-Romに収録されています。

【Table of Contents】

1. BASICS OF NEGOTIATING: Preparation; Formulation of Key Objectives and Deal Points; The Negotiating Team; Review of the Proposed Contract Terms; Agreement on Final Contract Language

2. ANTITRUST ISSUES IN MANAGED CARE CONTRACTING: Overview; Clinical Integration Issues for Provider Networks; Antitrust Regulatory Considerations Applicable to Pay for Performance (P4P) Arrangements; Messenger Model Contracting Concepts

3. KEY CONTRACT DEFINITIONS: Affiliates; Clean Claim; Covered Services; Effective Date; Emergency or Emergency Medical Condition; Medically Necessary; Member, Enrollee, or Beneficiary; Plan Sponsor or Payor; Products

4. PAYOR PROGRAMS AND POLICIES: UTILIZATION MANAGEMENT AND QUALITY ASSURANCE: Payor Programs and Policies; Utilization Management; Quality Assurance, Provider Credentialing, and Participation

5. RISK-BASED PAYMENT METHODS: Discounted Fee-for- Service; Per Diem Charge; Per Case Rates/Global Fees; Capitation; Percentage of Premium; Risk Pools; Pay for Performance; Government Risk-Based Payment Programs; Stark Law Considerations; Laws Regulating Physician Incentive Arrangements

6. TERM AND TERMINATION PROVISIONS: Term of the Agreement; Renewal Provisions; Termination Provisions; Compliance with Law and Termination; Rights and Obligations after Termination

7. INSURANCE REQUIREMENTS AND INDEMNIFICATION: Theories of Liability; Insurance Coverage Issues; Indemnification; Limitations of Liability; Tax Exemption Issues

8. OTHER CONTRACT PROVISIONS: Claims Submission; Payment; Records and Data Issues; Ownership of Medical Records and Authorization for Access; Subcontractor Relationships; Patient Relationships; Steerage; Assignment, Mergers and Acquisitions; Nondiscrimination; Sample Business Associate Agreement

9. DISPUTE RESOLUTION: Common Areas of Dispute; Internal Administrative Procedures; Nonbinding, Conciliatory Procedures; Binding, Adjudicatory Procedures; Procedures Required by Law

10. PROTECTING AGAINST INSOLVENCY: Termination Rights; Insolvency Insurance; Financial Reserve or Tangible Net Equity Requirements of Regulatory Agencies; Payment Delays and Losses Before Insolvency; Effective Contract Termination Provisions; Payor Risk Exposure in RBO Risk Withholds

11. GOVERNMENT PAYORS: Medicare & Medicaid Managed Programs; The State Children's Health Insurance Program

Appendix A - Glossary of Health Plan Contracting Terms

Appendix B - Table of Sample Clauses

Appendix C - Physician Group Practice Provider Agreement Template with Commentary