Week 1 discussion
Dq1
Managed Care and Current Trends
In your own words, define managed care and discuss how
managed care will impact healthcare delivery under healthcare reform
Dq2
Quality and Access
In your own words, explain the importance of why managed
care plans must provide quality healthcare.
Week 2 discussion
Dq1
Health Maintenance Organizations
In your own words, explain closed and open panel health
maintenance organizations and the continuum of managed care.
Dq2
Governance of Managed Care Organizations
In your own words, describe the makeup and function of the
board of directors in managed care plans
Week 3 discussion
Dq1
Provider Networks
In your own words, explain contracting approaches for
physicians and hospitals under managed care plans.
Dq2
Federal Regulations
In your own words, discuss the federal regulations and acts
to regulate health maintenance organization plans.
Week 4 discussion
Dq1
Provider Payment
Discuss the challenges and benefits of pay for performance
under managed care plans.
Dq2
Claims and Benefits
Describe the current challenges of claims capabilities,
including ICD-10-CM.
Week 5 discussion
Dq1
Legal Issues
Discuss the clauses and provisions that should be included
in provider contracts
Dq2
Fraud and Abuse
What steps should be taken to mitigate exposure and
liability when the federal government shows up to audit a healthcare
organization?
Week 6 discussion
Dq1
Utilization Review
Describe the three categories of utilization review and
explain why utilization review is the framework for utilization management.
Dq2
Medicare Advantage Plans and Medicaid Plans
Compare and contrast Medicare Advantage plans and Medicaid
plans.
Week 7 discussion
Dq1
State Regulations of Managed Care Plans
Outline the insurance market rules and rating factors and
how HIPAA impacts the rating factors.
Dq2
Federal Regulations of Managed Care Plans (graded)
Discuss the federal agencies that are responsible for the
oversight of HMOs, and discuss when federal regulations or state regulations
would apply to situations, such as HIPAA privacy standards
