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Medical Group Practice Policies and Procedures for Efficient Operation - 2009 Update
Apollo Managed Care Consultants, Feb 2009, Pages: 467
A ‘how-to’ manual of creative, cost-effective, quality-driven policies and procedures for the efficient management of medical group practices and other health care provider offices. Improve productivity, day-to-day medical practice management procedures including infection control, medical record and consent policies and procedures. Designed for modification to adapt to local practices and contract terms. Numerous forms, examples and other helpful tools. Resources include example materials to establish and measure practice metrics including physician staffing (by population) and office staff (by physician) requirements, develop a 'concierge' or retainer practice; hospitalist programs, compensation strategies, health law, disability evaluations, HIPAA, meet site visit standards by accrediting bodies, and web links.
These representative guidelines, policies and benefit interpretations are not intended to be construed or to serve as a certification and/or contractual agreement for payment or as a standard of medical care. Standards of medical care are determined on the basis of all of the facts and circumstances involved in an individual case and are subject to change as scientific knowledge and technology advance and patterns evolve.
Guidelines are designed to assist medical care professionals by providing a framework for evaluation and treatment and are not intended to either replace professional judgment or to establish a protocol for all patients with a particular condition. These guidelines are not intended as a sole source of guidance. Rather, each is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. Guidelines are not intended to replace clinical judgment or establish a protocol for all individuals and may not provide the only appropriate approach to diagnosing and managing a problem.
Each payer will have specific limitations and exclusions in the member’s certificate of coverage that may vary from one contract to another. It is important to verify the current specific applicable benefits for any individual with the payer. Unless indicated otherwise, policies apply to all fully insured HMO, POS and PPO plans and to all other plans, unless a specific limitation or exception exists. Unless otherwise specifically excluded, Federal mandates will apply to all plans. With respect to Medicare and Medicaid members, policies will apply unless Medicare and Medicaid policies extend coverage beyond that in these example benefit interpretations.
This manual is a toolbox of medical management policies and procedures provides a model structure for an efficient, physician-directed, medical care organization committed to cost effective, high quality care that will meet medical office accreditation and related standards. This manual has been developed to assist medical groups and hospitals in the implementation of successful medical management programs, particularly in relation to the delivery of outpatient managed health care services under ‘at risk’ health plan contracts. Unlike some other manuals, it cannot be taken ‘as is’ and distributed with minimal explanation. Instead, it is a model format for a Provider’s Manual to be tailored for use by each medical organization. Not all policies and procedures will be applicable to any given provider’s office. The process of evaluating each P & P for applicability to a given office will lead to improved strategies for the delivery of care to both the fee for service and managed care environments of care. The effort to improve the cost-effectiveness and the quality of ambulatory care has only just started with the purchase of this manual.
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