This course describes the “nuts and bolts” of managed care and thoroughly covers the issues surrounding healthcare reform. Selected modules from this course are valuable for management and clinicians throughout a hospital or health system. 

This certification program covers:

  • Various managed care models (HMO, PPO, POS)
  • Carve-outs, inpatient stop-loss, short-stay stop-loss, and withhold pools
  • Payment models proposed under healthcare reform and their differences
  • Physicians’ role in addressing utilization and quality of care
  • Key negotiation strategies
  • How payers evaluate their risks
  • Changes to HIPAA privacy laws included in ARRA
  • Principles behind outcomes-based reimbursement and incentives related to pay-for-performance programs
  • Relevant legislative changes affecting Medicare managed care

Objectives 

  • Identify key factors that influenced the development of managed care
  • Identify the various managed care models
  • Describe the insurer medical cost ratio (MCR) or medical loss ratio (MLR)
  • List cost-sharing mechanisms used in managed care and identify some of their important features
  • Explain coordination of benefits, managed Medicare organizations, and TRICARE
  • Explain the basic reimbursement methodologies used for physicians
  • List some popular capitation-based cost-control incentives
  • Describe a typical contract negotiation process
  • Identify the trends and direction of case management in today’s healthcare delivery system
  • Identify the clinical integration components of case management
  • List the two main issues to consider when discussing the safe use of EHRs
  • Discuss the potential results of EHRs’ emphasis in providing one standardized clinical data structure and presentation
  • Explain the purpose of NCQA
  • Describe major discussion points in the national healthcare debate
  • Explain the effects of increased consumer awareness
  • Describe the principles behind outcomes-based reimbursement and incentives related to pay-for-performance programs  

Course Information 

Pricing: $400 (HFMA members & non-members) 

Level: Intermediate

Prerequisites: None

Experience: Two or more years in the healthcare industry is recommended

Advance Preparation: None

Course Availability: One year from start date

Designed For: Managed care professionals and other healthcare management leaders

Instructional Method: Self-study

Format: Online

NASBA Field of Study: Specialized Knowledge & Applications

Approximate Time to Complete: 12 hours 

CPE Credits: 12

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