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

Fields of Study:

Finance: 2.0 hours   Specialized Knowledge: 10.0 hours

Total = 12

Format: Online

CPE: 12 hours 

Add to Cart     My HFMA Learning

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: memberservices@hfma.org. 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.