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


  • 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 

All-Access Members: Included with membership, no charge
Non-members: $299

Not a member? Join today and access this certification. You'll also unlock access to all of HFMA's on-demand learning and certification programs—all designed to sharpen skills, set you up for success, and ensure you're part of the solution.     

Instructional Method: Self-study

Designed for: Managed care professionals and other healthcare management leaders

Prerequisites: None

Advance Preparation: None

Level: Intermediate

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

Course Availability: One year from start date

Format: Online

Fields of Study:

  • Finance: 2.0 hours
  • Specialized Knowledge: 10.0 hours
  • Total hours: 12.0

Course participants can earn up to 12 CPE credits 

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Our ironclad guarantee

HFMA stands behind the quality of our programming. If you are not satisfied, we will gladly refund your money or provide you with a credit certificate toward any future HFMA National educational programs or select products. Contact HFMA directly at 3 Westbrook Corporate Center, Suite 600, Westchester, IL 60154, Attn: Professional Development, or call (800) 252-4362, ext. 2 or email: Please provide HFMA with your comments within two weeks of beginning the program.

Read additional information about CPEs for CPA licenses and education credits for HFMA certification maintenance.