Managed Care Law Manual (1-year Online Subscription)

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Managed Care Law Manual (1-year Online Subscription)

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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

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