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