Main description:

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.

Contents:

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