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Managed Care for Commercial, Medicare and Medicaid Populations - HCMG 7380

Course Length: 8 weeks

In this course, you will study the factors that impact emerging managed care product lines and competing alternative delivery systems. You will examine managed care market penetration in various markets and the strategic responses of hospitals, healthcare providers, integrated delivery systems and others.

Coursework Highlights

Coursework is designed for engagement and collaboration. Here is an example of just some of the assignments and projects you will complete as part of HCMG 7380.

  • Write a research paper based on a chosen topic, including a summary presentation.
  • Create PowerPoint presentations on topics like special markets.

Weekly Themes

Throughout the course, each week focuses on a different theme. Group discussions and coursework will align with that week’s theme, as well as its primary objectives.

Week 1 – Overview, Syllabus and Introduction

The first week of the course offers you an overview that covers the history of managed care, types of managed care organizations and elements of management and governance in managed care.

  • Learn the history of managed care and health insurance in the U.S.
  • Study the elements of governance structures of managed care organizations.

Week 2 – Network Contracting and Provider Payment

During week two you’ll study how managed care networks are developed, as well as the different types of contracting approaches and basic credentialing of providers. In addition, understanding the different methods for paying physicians and specialty care physicians is essential for the effective and efficient management of managed care plans. To this end, the steps in negotiating managed care contracts are vital to quality care and cost management activities.

  • Study the regulatory constraints on payment methodologies, and the circumstances that bring those constraints into effect.
  • Examine the basic approaches to pay for performance.
  • Learn the importance of "hold harmless" clause in managed care contracts.

Week 3 – Management of Utilization and Quality

In week three you’ll examine the basic measurements of provider utilization. These measurements include medical-surgical utilization management, disease management concepts, the importance of physician practice behavior in managed care and the general requirements for using data in medical care management. The importance of prescription drug benefits in managed care practice and having a pharmacy benefit management information system will also be covered.

  • Study the key attributes of managing basic medical-surgical utilization in different types of managed care plans.
  • Explore how conventional case management differs from disease management.
  • Learn the principles of using data to manage health care delivery systems.

Week 4 – Management of Utilization and Quality (Continued)

Week four explores how health disparities affect managed care programming. Coursework also explores the difference between behavioral health managed care and medical-surgical managed care as well as how managed care plans handle health promotion and disease prevention. Total Quality Management (TQM) as an integral part of managed care operations and administration will be covered in detail. You will also look at how accreditation practices and organizations play a key role in maintaining and providing quality in managed care organizations.

  • Learn about cultural health disparities and their relation to managed care operations.
  • Study the components of a total quality management program and its use in managed care programming.

Week 5 – Sales, Finance and Administration

In week five you will study the importance the key components of a well-run managed care organization, including enrollment and billing, marketing and sales, and health care fraud prevention.

  • Explore the difference between employer-sponsored group health coverage and individual coverage, and how the Patient Protection and Affordable Care Act will affect them.
  • Analyze the basic flow of funds in a typical managed care organization.
  • Study the role of information services in a payer organization.

Week 6 – Special Markets

During week six you’ll learn about other types of managed care organization, such as Medicare, Medicaid, and the military plans, and explore how the Medicare Modernization Act and the Patient Protection and Affordable Care Act have impacted them.

  • Learn about the different types of Medicare components, including Medicare D and Medicare Advantage programs.
  • Examine key legislative events in military health care that resulted in the implementation of the current program.
  • Compare and contrast the financing and organization of the United States health care system with those in other nations.

Week 7 – Laws and Regulations

Week seven’s coursework focuses on state and federal regulations that impact managed care organization operations and administration, with emphasis on the new Patient Protection and Affordable Care Act.

  • Explore what is included under the administrative simplification portion of HIPAA and its relationship to managed care organizations.
  • Analyze how ERISA, COBRA, and HIPAA are applied to managed care.
  • Examine the overall scope and impact of the Patient Protection and Affordable Care Act on health insurance and managed care organizations.

Week 8 – Comprehensive Exam

Week eight marks the last week in this course. In this week, you will have a comprehensive exam on all material covered in the course to date.

Get Started

To learn more about this course, or other courses in the online MBA from Our Lady of the Lake University, call 855-275-1082 to speak with an admissions adviser or request more information.