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HM 550 Insurance, Reimbursements & Managed Health Care Syllabus

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Printable Copy of The ExamAccess Online ExamCourse Evaluation Form

COURSE OVERVIEW: Welcome to the online CE course; HM 550 – Insurance, Reimbursements & Managed Health Care

Upon successful completion of this course, students are awarded 50 contact hours of continuing education creditsCourse Code: HM 550.

This online CE course is a comprehensive course in Managed Care, as well as the Insurance Industry in general. Students will examine a comprehensive and foundational overview of the history of health insurance and in particular Managed Care. The text book used is most current and up to date and provides students with the latest policies and changes regarding health care insurance/benefits as well as political processes that have affected such changes in the marketplace. The content in this course moves from intermediate level content to move advanced content and concepts as the student progresses. Including in the learning in this course is comprehensive content on health benefit plans and the various types of health plans and payers today. Students will learn all about risk and risk-sharing and risk contracts in managed care. Provider networks are presented, how they are structured, how they work and what outcomes are being seen with such structures in place. Students will study comprehensive content on provider payment structures, including cost sharing methodologies, risk-based vs. non-risk based payment structures, value based payment, and many others.

Learning moves on to Utilization Management concepts and methods and how these are incorporated into the overall insurance health plans and managed care plans today, as well as the role of case managers in utilization management. Principles of Quality Management are explored. Students will also examine and learn about insurance and managed care health plan and organizational accreditations, certifications and award programs. Included in the course content is the administrative practices related to health insurance and managed care plans and organizations where students will learn about analytics and informatics, sales, actuarial services, eligibility issues, claims, benefits, fraud and abuse issues, and management challenges. There is a significant study of Medicare and Medicaid including Medicare Advantage where students examine and learn all about these governmental benefit plans, how they work and what they mean for health care organizations, providers and for patients. Students will also study issues related to laws and regulations in health insurance and managed care. Course Code: HM 550. Continuing Hours of Education = 50.

Course Refund & AIHCP Policies: access here

Stethoscope and book in a hospital

This Course is Board approved. The American Institute of Health Care Professionals Inc. is an Approved Provider of Continuing Education by the Florida State Board of Nursing and the District of Columbia Board of Nursing. CE Provider # 50-11975.The American Institute of Health Care Professionals, Inc. is a licensed Continuing Education Provider in the State of California, Board of Registered Nursing, Provider # CEP 15595. Access Info

The American Institute of Health Care Professionals Inc: is a Rule Approved Provider of Continuing Education by the Arkansas Board of Nursing. CE Provider # 50-11975.
The American Institute of Health Care Professionals Inc: is a Rule Approved Provider of Continuing Education by the Georgia Board of Nursing. CE Provider # 50-11975.
The American Institute of Health Care Professionals Inc: is a Rule Approved Provider of Continuing Education by the South Carolina Board of Nursing. CE Provider # 50-11975.
The American Institute of Health Care Professionals Inc: is a Rule Approved Provider of Continuing Education by the West Virginia Board of Examiners for Professional Registered Nurses. CE Provider # 50-11975.
The American Institute of Health Care Professionals Inc: is a Rule Approved Provider of Continuing Education by the New Mexico Board of Nursing. CE Provider # 50-11975.

Instructor/Course Author: Dominick L. Flarey, Ph.D, MBA,RN-BC, ANP-BC, GC-C
Link to Resume: access here

Email: info@aihcp.org

This is a guided, independent study CE Course. You are to study and progress at your own rate. There are no written assignments. It is recommended that you follow this process for completion of the course :

1. Order your textbook for the course. Information and a link to order the book online are presented below.

2. Review the course objectives.

3. You are required to read/review all chapters in the assigned textbook, unless otherwise indicated by your instructor in this syllabus. As you read/review each chapter, you may want to stop and identify the corresponding questions on the exam related to the material of that chapter, and answer the questions on your printed out copy of the examination. You can obtain a printed copy of your examination simply by clicking on the link at the top of this syllabus “Printable Copy of The Exam.” This will allow you to work with your exam as you study the text book (s) and progress through your course. Then, when you have completed your examination using the printable copy, you will be ready to transfer your responses into the computer based examination program for final submission and grading. You can proceed doing this with each chapter, until you have completed your study of the textbook. Please read/review each chapter in sequence. Do not “skip” ahead, as each chapter builds upon the materials in the previous chapter.

4. Once you have completed all of the chapters in the textbook, you can proceed to your final online examination by clicking the “Access Online Exam” link below the course banner at the top of this syllabus. You can also download the exam as a PDF file by clicking on the “Printable Copy of The Exam” link next to Access Online Exam. If you wish you can print this file out as a printed off copy of your examination. Once you access the online exam you will see a screen that will ask you to input your Name, E-mail address, and your student ID/AH Number (AH####). Please fill out all of the requested information accurately. If you do not, we will not be able to identify who took the exam and your answers will be lost. The following slide will welcome you to your exam and present the introduction slide with further instructions on how to take the exam. Answer the questions to the best of your ability. There is only ONE correct response for each question.

5. When you have answered the final question, it will ask you to submit your answers. It will then show you your grade for the exam, and if you passed the exam it will allow you to review your answers. If you passed, the close button in the bottom right hand corner will take you to the course evaluation form. At which time, please fill out an evaluation so your grade can be processed. Once received, we will send you an e-mailed copy of your exam with the correct and incorrect answers.

5a. If you did not pass your examination, you will receive a notification stating failed. You will not receive any feedback on your answers. Please press the close button on the bottom right hand corner to exit your exam. At which point, contact the Assistant Executive Director @ Mark@aihcp.org,  for a chance to retake the exam. If you fail on your second attempt, you will fail the course and have to pay to retake it.

6. If you have successfully completed the examination with a passing score, we will process your CE Certificate, which will include the course title, the awarded contact hours of continuing education, and the date of completion. Your CE certificate will be e-mailed to you as a PDF file. You can expect to receive your certificate (via e-mailed PDF file) within 2-3 business days upon receipt of the completed evaluation form. No CE Course Certificate will be processed without a completed course evaluation. If you missed the course evaluation link after the exam, you can alternatively click the “Course Evaluation Form” at the top of this syllabus. Please note that the Organizations and the licensing Boards that provide our CE approvals all require that a course evaluation be completed by the course participant before a CE Course Certificate may be awarded; as such there are no exceptions. A course evaluation must be completed in order to receive your CE Course Certificate.

TIME FRAME: You are allotted two years from the date of enrollment, to complete this course. There are no set time-frames, other than the two year allotted time. If you do not complete the course within the two-year time-frame, you will be removed from the course and an “incomplete” will be recorded for you in our records. Also, if you would like to complete the course after this two-year expiration time, you would need to register and pay the course tuition fee again.

TEXTBOOKS: There is one (1) required textbook for this course.

Health Insurance and Managed Care, 5th edition. Peter R. Kongstvedt. Jones & Bartlett Learning; 2019: ISBN-10: 128415209X ISBN-13: 978-1284152098

This book is available for purchase directly from the publisher at a special 40% discount via our AIHCP portal at the publisher’s website. To purchase now at the 40% discount: access here

ADDITIONAL ASSIGNMENTS:

VIDEOS: The following VIDEOS are required viewing for this course. The contents /teaching of the videos provides complimentary teaching for the overall learning objectives of this course. Just click on the “access” link for each video below for viewing.

1. Birth of the HMOaccess here

2. History of Managed Care: access here

3. The American Health Care Systemaccess here

4. Managed Care Organizations: access here

5. Managed Care 101access here

6. The Affordable Care Act: access here

7. Medicare Overview: access here

8. The Parts of Medicare: access here

9. Medicare Part D: access here

10. Paying Doctors: access here

11. What are capitated payments?: access here

12. Medicaid: access here

13. Medicare Supplement Plans: access here

GRADING: You must achieve a passing score of at least 70% to complete this course and receive the 50 hours of awarded continuing education credit. There are no letter grades assigned. You will receive notice of your total % score. Those who score below the minimum of 70% will be contacted by AIHCP and will be permitted one more attempt to retake the online examination.

FINAL EXAMINATION: It is recommended that you click on the “Printable Copy of Exam” near the top of the syllabus. It will download as a PDF file. Below are detailed instructions on how to take your exam.

1). When ready to start your final examination for the course, please click on the “Access Online Exam” link near the top of the syllabus.

2). You will be prompted to input your Name, E-mail Address, and Student ID # (AH####). You must fill this out, the exam will not allow you to proceed if you do not. It is very important that you use your full name, your valid e-mail address and your student ID/AH Number. If you do not input your correct information, we will have no way of identifying your exam and it will be deleted! All unidentifiable exams are deleted!

3). Next you will be taken to the introduction screen for your exam. There will be detailed instructions on how to take the online exam. Please review them and when ready click the “Continue” button on the bottom right hand side of the screen to begin your exam.

4). When you have answered all of the questions and are happy with your answers, the exam will prompt you to either “SUBMIT ALL” or “RETURN TO EXAM”. If you are ready press “SUBMIT ALL”.

5). If you received a passing score, you will receive a “Congratulations, you passed” screen with a green check mark. You will have a chance to review your questions and answers. A copy of your exam will be e-mailed to you within 1-2 business days.

5a). If you failed the exam, you will receive a “You did not pass” with a red X. You will have no chance to review your questions and answers. At this point, please contact Administration, Mark D. Moran, Assistant Executive Director for instructions on re-taking the online examination. You may retake the online examination one time. You will receive full instructions regarding the re-take of the examination.

6). After receiving a passing score, click the “CLOSE” button in the bottom right hand corner to close out of the exam and be redirected to the course evaluation form. You must fill out the course evaluation form in order for your grade to be processed and for you to receive an CE certification.

Note: all of our Examinations are Copy Written

COURSE EVALUATION: upon submitting your responses to the examination questions, you are required to complete the online Course Evaluation Form.  This will take you directly to the online evaluation form. Complete the evaluation and be sure to click the “submit” button. CE certificates will not be sent unless a course evaluation is completed.

COMMUNICATION: this is a self-directed, independent study course. However, you may certainly submit to us questions or comments regarding the course materials. We will be sure to forward any questions you may have to the author of the course. You will then receive a follow-up response from the author. All of our course authors are fully educated and credentialed in the practice of Health Care Management. You may email any questions to: info@aihcp.org. Please be sure to include the full title of the course you are in, as well as the course code (provided above). If you have any questions at all or need any assistance, please do not hesitate to contact us.

TECHNICAL SUPPORT CENTER: Our Technical Support Center is open Monday-Friday; 9:00 am to 5:00 pm (EST).  You may e-mail technical support at: admn@aihcp.org   You may also phone us at: 330-652-7776. If you leave an e-mail after normal business hours, the Support Center will respond to you as soon as they open up the next business day.

INTERACTIVE STUDENT FACEBOOK GROUP
Please join the Interactive Facebook Group for Health Care Management!

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We host a private (students only) Facebook page for Health Care Managers. This page is dedicated for private use by all students in our Health Care Manager courses. We highly encourage all of our students to “join” this private group. The group is used for:

  • Providing interactions between all students in the Health Care Manager program.
  • All members may post on the page as well as download documents and photos.
  • Interactions between students and faculty.
  • Meeting new colleagues/friends who have the same interests in Health Care Management.
  • Providing a medium for Chat sessions among members of the group.
  • Providing new information to all student on an ongoing basis via posts in the room.
  • Stimulating discussions related toHealth Care Management and other professional issues/topics.
  • Sharing articles, links to recommended websites, links to videos as well as links to events and other education resources.
  • Our staff provides up to date articles for your review. Articles are added almost on a daily basis. Reviewing the information is voluntary but highly recommended.

Joining the private Facebook group is voluntary. We do highly encourage you to join and participate. Your participation will enhance your learning and provide a platform for networking with your colleagues. Join the group today! You must ask for permission to join this group. Our staff will receive your permission notice and will verify your student status and then authorize your membership to the group page.

Important Information: You must have a Facebook account to join this group. If you have a Facebook account, just click on the link below and you will be taken to the Facebook sign in page. You would then log into your account. You will be on the Health Care Manager private group page. Once you have clicked on the link, a notice will be sent to our administrative office and you will be authorized to the page. On your Facebook page, the group page will be listed on the left hand side of your page. You can click it at any time and enter the private page. If you do not have a Facebook account, it is easy to open one. The link below will take you to the sign in page and you can click on the link to open an account. Facebook accounts are free.

Click here to access the Health Care Manager Private Facebook page

Click here to access Health Care Management & Leadership Public Facebook page

AIHCP BLOG: Please visit our interactive web blog. Students and certified members are encouraged to visit our blog frequently. You will find useful articles, news, posts and much more related to the specialty area of Certification you are pursuing. Click the link above to access the blog. Then, click on the link on the right hand side that corresponds to the subject area you are studying. Feel free to posts replies, comments and news. Register to become active on the blog and contribute your own unique information for all to see and share. Sharing and interacting with your peers is an excellent learning process. By sharing you contribute to the ever growing body of knowledge in your specialty area.

STUDENT RESOURCE CENTER: Please access our student resource center. The Resource Center contains all of our current policies, as well as important information regarding classroom and examination accesses. Also included are trouble-shooting tips when a student has any difficulties with classroom or examination accesses. The Resource Center also provides other information regarding our continuing education and certification programs. Access to online libraries is also provided. To Access the Student Resource Center: click here.

Discussion Boards:  Please access the Discussion Boards by clicking on the Tab on the left side of your computer screen. The Discussion Boards are provided for our students as means to communicate with others taking courses in our Health Care Manager Courses and Programs.  You have full access to the Discussion Boards throughout the time you are enrolled in a course. They are a great means to meet others who are studying Health Care Management, exchange ideas, post questions and ideas, provide responses to other’s questions, provide links to outside resources and more.  Once you access the Discussion Boards, simply follow the instructions to create your own account and start reading and posting.

E-Learning Library: Please access our E-Learning Library by clicking on the Tab on the left side of your computer screen. The E-Learning Library is a free service for all of our students. It is an ever-growing library of FREE E-Books that you may access at any time. The books are produced by us professionally on a wide array of health care related topics. You may read and or download them for later references. We frequently add new E-Books to the library on an on-going basis. The E-Books are not related to this course and so are not required readings for this course.

Malpractice Insurance: Many are interested in seeking out companies that provide health care professional malpractice insurance. We have compiled a list of companies that you may contact directly regarding this. Most companies will provide you with a quote online. For information, click here.

Submit a Testimonial: Students and certified members may submit a testimonial to our public Testimonials Page. Visitors to our website, especially those considering our certification programs, are keenly interested in hearing about the experiences of health care professionals who are enrolled in our programs. To submit a Testimonial, simply access the online Form: Access Here. You may also preview our current Testimonials Page Here.

COURSE OBJECTIVES: Upon completion of this course, you will be able to:

1. Understand how health insurance and managed care came into being.
2. Understand the forces that have shaped managed care and health insurance in the past.
3. Understand the major obstacles to managed care historically.
4. Understand the major forces shaping health insurance and managed care today.
5. Understand the core components of health benefits coverage.
6. Describe the sources of health benefits coverage.
7. Explain the differences in bearing risks for medical costs.
8. Understand the basic types of health insurers and managed care organizations
9. Describe the differences between types of payers.
10. Understand the basic elements of payer-provider contracts.
11. Understand service areas and access standards.
12. Understand basis credentialing.
13. Understand the basic types of physicians and other health care professionals in a typical network.
14. Understand the basic types of hospitals, ambulatory centers, and other health care facilities in a typical network.
15. Understand the basic types of integrated delievery systems and their relationships between hospitals, physicians and with payers.
16. Understand contracting for ancillary services.
17. Understand the differences between payments and reimbursements
18. Be familiar with standardized electronic transaction code sets used for provider billing and payment.
19. Identify the basic elements of risk-based and non-risk-based provider payment.
20. Describe the most common forms, modifiers, and variations of provider payments for: physician services, hospitals, ambulatory medical facilities, pharmaceuticals, and ancillary services.
21. Describe the common forms of payment that combine hospital and physician payment.
22. Identify the basics of value-based payment (VBP) and pay for performance (P4) used by payers in the private sector.
23. Recognize the different approaches to managing wellness and prevention.
24. Identify and describe the basic metrics and measures used to assess and monitor health plan medical costs and utilization.
25. Describe the basic components of utilization management for medical services, including prospective, concurrent, and retrospective review.
26. Explain the basic concepts underlying disease management, case management, transition management, and Patient-Centered Medical Home.
27. Describe the basic components of quality management, including structure, process, and outcome.
28. Understand the purpose and scope of external review and accreditation of managed care plans.
29. Describe the basic structure of governance and management in payer organizations.
30. Identify the basic elements of internal operations of payer organizations, including:information technology, marketing, sales, insurance exchanges, underwriting and premium rate development, eligibility, enrollment and billing, claims and benefits administration, members services, appeal rights, statutory accounting, statutory net worth, and financial management.
31. Be familiar with the common potential problems and challenges faced by payers, including those specific to provider-owned or sponsored payer organizations.
32. Explain the Medicare benefit structure.
33. Understand the basic elements and requirements for private Medicare Advantage Plans.
34. Understand the basic elements and requirements for private managed Medicaid plans.
35. Explain the difference between plans serving the typical Medicare and /or Medicaid population and those serving beneficiaries who have special needs and/or who are dual eligible.
36. Understand key legal and regulatory issues in the government entitlement programs that affect private managed care plans.
37. Understand the unique key aspects of how Medicare pays Medicare Advantage Plans.
38. Explain at a high level the basics of the Medicare Quality Bonus Payment Program, also called Medical Stars or simply Stars.
39. Describe the basic structure of state and federal oversight of managed care organizations (MCOs).
40. Identify key state and federal laws and regulations governing managed care.
41. Explain the interaction of state and federal laws affecting health plans and payers, including, preemption and the role of the courts.
42. Demonstrate an understanding of the role of nongovernmental organizations in the oversight and regulation of payer organizations.

COURSE CONTENT:

  • History of Managed Health Care & Health Insurance
  • The Managed Care backlash
  • The changing health care market
  • Health benefits coverage
  • Sources of benefits coverage and risks
  • Types of payers
  • Contracts and Contracting
  • Service areas, access standards & network adequacy
  • Physician credentialing
  • Types of physician contracts
  • Hospitals and ambulatory facilities
  • Physician self-referral
  • Integrated delivery systems
  • Vertical integration
  • Ancillary services
  • Network maintenance
  • Provider payments
  • Cost sharing
  • Standardized code sets
  • Risk-based vs. non-risk based payment
  • Value-based payment
  • Physician payment
  • Facility payment
  • Combined payments of hospitals and physicians
  • Payment for ancillary services
  • Payment for prescription drugs
  • Health prevention and wellness
  • Measuring utilization
  • Medical necessity and benefits coverage determination
  • Utilization management
  • Appeals of coverage denials
  • Disease management
  • Case Management
  • Transition management
  • Patient-centered medical home
  • Utilization management of ancillary services
  • Management of pharmaceutical benefits
  • Quality management
  • Health plan accreditation, certification, and recognition
  • Governance and management
  • Information technology
  • Administrative simplification under the HIPA act.
  • Analytics and informatics
  • Marketing and sales of commercial products and services
  • Actuarial services, underwriting, premium rate development
  • Eligibility, enrollment and billing
  • Claims and benefit administration
  • Fraud, waste and abuse
  • Member services
  • Financial management
  • Operational challenges in the payer industry
  • Medicare
  • Medicaid
  • MCO structure and Organization
  • State oversight and regulation
  • Conflicts, preemption and the role of the courts
  • Role of nongovernmental organizations