Free for HFMA Members
$399 for Non-members


Health Plans
Hospitals and Other Providers
Physicians and Other Practitioners

Career level:

Experienced Professional

Recommended for:

Healthcare Economics
Managed Care
Payer Contracting
Physician Practice
Revenue Cycle

Delivery Method:

QAS Self Study

Advance Preparation:


Field of Study:

Finance: 2.0 hours
Specialized Knowledge: 10.0 hours



Course Availability:

18 Months

Certification | Intermediate | Managed Care

Certified Specialist Managed Care (CSMC)

Certification | Intermediate | Managed Care

Certified Specialist Managed Care (CSMC)


This online program describes the nuts and bolts of managed care and thoroughly covers the issues surrounding healthcare reform. Selected course modules from this online program 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
Estimated course completion time: 10-12 hours
After this program, you'll be able to..
  • 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 EHR's 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
Online program last updated: 5/24/2018

Related Courses | Managed Care

Course | Overview | Managed Care

Mgd Care: Reimbursement Methodologies

This course discusses financial management, the central thread that interconnects the various elements of managed care. It explains various reimbursement methodologies commonly used in managed care and the underlying assumptions and risk management funding mechanisms that are responsible for these reimbursement methodologies. This course describes basic and advanced reimbursement methodologies used for hospital services and basic reimbursement methodologies used for physicians and other professionals.

Estimated course completion time: 1 hour and 15 minutes

Course | Overview | Managed Care

Mgd Care: Overview of Managed Care

This course provides an overview of the state of managed care today and discusses how and why it has evolved. It also identifies major initiatives that are currently affecting managed care and will continue to do so in the future, as the U.S. continues to implement the reforms associated with the passage of the Patient Protection and Accountable Care Act (ACA) in March 2010. The course offers a solid foundation of knowledge that will provide necessary context for the more detailed information presented in subsequent courses in this series.

Estimated course completion time: 45 minutes

Course | Overview | Managed Care

Mgd Care: Trends in Healthcare Policy

This course explores trends in the ongoing development of state and federal healthcare policies and covers topics related to the national healthcare debate. It also discusses increased employer and consumer awareness and its impact on healthcare policies, outcomes-based reimbursement approaches, and improved outcomes and increased value through coordination of care. The course examines the key issues behind healthcare reform and the main elements of the 2010 law.

Estimated course completion time: 30 minutes

Course | Overview | Managed Care

Mgd Care: Healthcare Delivery Systems

This course discusses the healthcare delivery system in the U.S. and describes how various managed care models affect the quality and cost of care. It also describes the various relationships between providers and payers. Finally, it addresses cost-sharing mechanisms such as copayments, coinsurance, and out-of-pocket maximums that managed care models use to direct their members' choices of providers and services.

Estimated course completion time: 1 hour