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CM 580 – Managed Health Care


This is the fifth and last course in the case management continuing education program. This comprehensive course focuses on managed health care. 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: CM 580. Contact hours of education = 60.

Level of Complexity: Intermediate to Advanced

This course is particularly designed for those who would like to apply for Fellowship certification as a “Fellow” in the American Academy of Case Management. This course is also offered to all health care and management professionals who may be interested in taking it.

Instructor/Course Author:  Dominick L. Flarey, Ph.D, MBA, RN-BC, NEA-BC, FACHE

Link to Resume


BOARD APPROVALS: The American Institute of Health Care Professionals (The Provider) is approved by the California Board of Registered Nurses, Provider number # CEP 15595 for 60 Contact Hours.  Access information

This course, which is approved by the Florida State Board Of Nursing (CE Provider # 50-11975) also has the following Board of Nursing Approvals, for 60 contact hours of CE

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.

Course Refund & AIHCP Policies: access here

TIME FRAME: You are allotted two years from the date of enrollment, to complete all of the courses in this continuing education program (all five (5) courses). There are no set time-frames per course, other than the two year allotted time. If you do not complete the courses 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 courses after this two-year expiration time, you would need to register and pay the course tuition fee again.

TEXTBOOK: There is one 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


There are Online Videos that are required for viewing for this course as well. Once enrolled into the course, students are provided with full information regarding Video Viewing and assignments. Videos are NOT required to be purchased.

GRADING: You must achieve a passing score of at least 70% to complete this course and receive the 60 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 the American Institute of Health Care Professionals and options for completing additional course work to achieve a passing score, will be presented.

COURSE EVALUATION: upon submitting your responses to the examination questions, you are required to complete the online course evaluation. Course evaluations are accessed from the online classroom. A course evaluation must be completed in order to receive the CE course certificate.


* Examination Access: there is link to take you right to the online examination program where you can print out your examination and work with it. All examinations are formatted as “open book” tests. When you are ready, you can access the exam program at anytime and click in your responses to the questions. Full information is provided in the online classrooms.

Student Resource Center: there is a link for access to a web page “Student Resource Center.” The Resource Center provides for easy access to all of our policies/procedures and additional information regarding applying for certification. We also have many links to many outside reference sites, such as online libraries that you may freely access.

* Online Evaluation: there is a link in the classroom where you may access the course evaluation. All students completing a course, must, without exception, complete the course evaluation.

* Faculty Access Information: you will have access to your instructor’s online resume/biography, as well as your instructor’s specific contact information.

* Additional Learning Materials: some faculty have prepared additional “readings” and /or brief lecture notes to enhance your experience. All of these are available in the online classrooms.




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.


  • 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