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Editorial Board
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Preface
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Introduction
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Volume I
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MANAGED CARE ORGANIZATIONS, AFFILIATED ENTITIES, AND INTEGRATED DELIVERY SYSTEMS
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1
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Introduction
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2
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Types of Managed Care Organizations
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3
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HMO Models
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4
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Physician Group Formations
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5
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Physician-Facility Affiliations
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6
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Virtual Integration
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7
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Global Capitation
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8
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Providing the Insurance Function
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9
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Reference Materials
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Appendix A
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Example ACO Participant Agreement Language
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Appendix B
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Example ACO Participant Agreement Amendment Language
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Appendix C
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Sample ACO Case Study
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Appendix D
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Care Coordination Toolkit
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OVERVIEW OF FEDERAL REGULATION
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1
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Introduction
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2
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Operational Issues
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3
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Coverage Issues
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4
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Reference Materials
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STATE REGULATION OF MANAGED CARE
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1
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Introduction
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2
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Contracts with Providers
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3
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Contract with Enrollees
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4
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Mandatory Health Service Coverage
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5
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MCO Operations
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Appendix A
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State Any-Willing-Provider Laws
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Appendix B
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State Statutes Requiring Coverage of Autism
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Appendix C
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States with Extended Dependent Coverage
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Appendix D
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Genetics and Health Insurance State Anti-Discrimination Insurance Laws
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Appendix E
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State Laws Related to Infertility Treatment
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Appendix F
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State Dependent Coverage Beyond the ACA
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BUSINESS STRUCTURES
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1
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General Partnership
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2
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Limited Partnership
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3
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Registered Limited Liability Partnership
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4
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Limited Liability Company
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5
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Corporation
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ANTITRUST
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1
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Introduction
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2
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Overview: Federal Antitrust Statutes
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3
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Fundamental Antitrust Principles
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4
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Exemptions Applicable to Health Care
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5
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Agreements Related to Price or Reimbursement Rates
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6
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Agreements Affecting Market Allocation
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7
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Tying Arrangements
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8
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Group Boycotts and Concerted Refusals to Deal
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9
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Joint Action in Relation to Managed Care Contracting
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10
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Mergers and Acquisitions
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11
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Joint Ventures and Other Provider Networks
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12
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Enforcement
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13
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Reference Materials
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EXTERNAL REVIEW
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1
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Introduction
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2
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State External Review Laws
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3
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Accreditation Standards Applicable to External Review
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4
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Medicare Managed Care External Review
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Appendix A
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Model External Review Request Form
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Appendix B
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Model Notice of Appeal Rights
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Appendix C
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State External Appeals Review Processes
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Appendix D
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Revised Model Notice of Final External Review Decision
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ERISA
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1
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Introduction
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2
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Plan Document Requirements
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3
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ERISA Plan Fiduciaries
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4
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Preemption Under ERISA
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5
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Standard of Review
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6
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Remedies Under ERISA
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7
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Ways to Avoid Liability
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Appendix A
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Fiduciary Responsibilities Under a Group Health Plan
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Volume II
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TRENDS IN MANAGED CARE LITIGATION
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1
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Status of Managed Care Litigation
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2
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Activities That Can Trigger Claims
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3
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Theories of Liability
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CONTRACTING
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1
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Introduction
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2
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Negotiation Strategies
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3
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Contract Structure
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4
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Contract Provisions
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5
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Legal Issues Arising from Contracting Activities
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Appendix A
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Checklist: Questions to Ask When Reviewing MCO Standard Contracts
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Appendix B
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Sample Management Contract
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ACCREDITATION OF HEALTH CARE ORGANIZATIONS
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1
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Introduction
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2
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Accreditation Organizations
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3
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Types of Accreditation
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4
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Accreditation Standards
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5
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Challenging Accreditation Decisions
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6
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Performance Measurement
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7
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Legal Issues in Accreditation
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CREDENTIALING
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1
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Introduction
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2
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Managed Care Organization Responsibility for Credentialing and Monitoring
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3
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Scope of a Managed Care Organization's Duty to Credential
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4
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Credentialing and Fair Process
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5
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Economic Credentialing
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6
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Antitrust Concerns in Excluding Providers
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7
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Health Care Quality Improvement Act of 1986
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FRAUD AND ABUSE ISSUES AFFECTING MANAGED CARE ENTITIES
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1
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Introduction
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2
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Prohibited Conduct Under the Anti-Kickback Statute
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3
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Safe Harbor Regulations
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4
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Sanctions
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5
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Prohibited Conduct Under Physician Self-Referral Legislation (Stark I and Stark II)
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6
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Racketeer Influenced and Corrupt Organizations Act (RICO)
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7
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The False Claims Act
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SPECIAL ISSUES FOR TAX-EXEMPT ORGANIZATIONS IN MANAGED CARE
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1
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Introduction
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2
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Requirements for Tax-Exempt Status Under Section 501(c)(3)
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3
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Tax Exemption for Specific Types of Managed Care Entities
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4
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Qualification of Hospitals for Exemption from Ad Valorem Taxation
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5
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Factors That Qualify Specific Property for Exemption from Ad Valorem Taxation
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Appendix A
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Form 990—Return of Organization Exempt from Income Tax
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Appendix B
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Form 990—Schedule H (Hospitals)
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CONTRACTING WITH THE GOVERNMENT
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1
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Introduction to Contracting with the Government
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2
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Medicare Managed Care
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3
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Medicaid Managed Care
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4
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Sanctions and Penalties
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PHARMACY
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1
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Pharmacy Service Providers
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2
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Drug Products
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3
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Dispensing and Quality Assurance
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4
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Fraud, Abuse, Kickbacks, and Self-Dealing
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BEHAVIORAL HEALTH CARE
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1
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Introduction
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2
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History of Managed Behavioral Health Care
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3
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Regulation of Managed Behavioral Health Care
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4
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Any-Willing-Provider Statutes
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5
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Confidentiality of Behavioral Health Information
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6
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Accreditation of Managed Behavioral Health Care Organizations
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Appendix A
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State Mental Health Parity Laws
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MARKETING
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1
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Introduction
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2
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Federal Law
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3
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State Law
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MANAGED CARE COMPLIANCE
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1
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Introduction
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2
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What Is a Corporate Compliance Program?
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3
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Developing a Corporate Compliance Program
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4
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Designing a Corporate Compliance Program
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5
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Risk Assessment in Managed Care
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6
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OIG Compliance Program Guidance
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7
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Employee Education and Training
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8
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The Federal Sentencing Guidelines
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9
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The Sarbanes-Oxley Act
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ELECTRONIC INFORMATION IN MANAGED CARE
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1
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Introduction
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2
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Coverage and Reimbursement
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3
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Legal Issues in E-Medicine
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4
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Web Site Disclaimers
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5
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Informed Consent
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6
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MCO Uses of E-Medicine
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7
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Cybersecurity
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Appendix A
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Sample Compliance Checklists for Electronic Health Records
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Appendix B
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Security Risk Analysis Tip Sheet: Protecting Patients’ Health Information
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Appendix C
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Reassessing Your Security Practices in a Health IT Environment: A Guide for Small Health Care Practices
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Appendix D
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Sample Privacy and Security Policies—Workforce at-a-Glance Guidelines
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Appendix E
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Sample Seven-Step Approach for Implementing a Security Management Process
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Appendix F
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OCR Cyber Attack Checklist
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RESOURCES
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Acronyms
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Glossary
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