MH684 Managed Health Care Discussion 1

Describe some reasons why managed care was perceived negatively in the past. Discuss why you believe the concept of managed care could improve the health care industry in the future.

   

MH684 Managed Health Care Discussion 2

Define the different forms of cost-sharing and how they differ. Define the cost-sharing provisions that accompanied the Affordable Care Act.

   

MH684 Discussion Question 6

Discussion Question 6

Describe the four categories of Medicare Advantage plans.

Describe the five main types of Medicaid managed care plans.

   

MH684 Discussion Question 4

Discuss the differences between case management and disease management. Discuss what patient-centered medical homes are and how they can be effective in managing complex patients with multiple comorbidities.

 

 

MH684 Discussion Question 3

A. Discuss the differences between risk-based and non-risk based payment

B. Discuss the following payment mechanisms that can be used to reimburse health care providers:

·        Fee-for-Service

·        Bundled Payment

·        Capitation

 

MH684 Discussion 5

Discussion 5

The concept of vertical integration was initially introduced in Lessor 2 and was revisited in this lesson. This is an organizational structure in which physicians, hospitals, and health insurers are all part of a single entity. Discuss some operational challenges that health systems and hospitals may have when deploying their own health plans.

   

MH684 Managed Health Care - Capstone Project

Capstone Project

MH684 Managed Health Care

(300 Points)

Overview

You'll be required to submit a 12-16 page report which answers the prompts for each lesson. In your report, make it clear which prompt your response pertains to.

 

Lesson 1: Health insurance and managed healthcare: its origins and developments (2 pages/30 points)

A. Describe some reasons why hospitals, health systems, and health plans are increasingly employing physicians directly.

B. Describe an ACO and the Medicare Shared Saving Program and how these can result in improved patient outcomes while also reducing costs.

C. Other than establish the creation of ACOs, identify and describe five provisions of the Affordable Care Act and their impact on the healthcare industry.

Lesson 2: Health Plans, Players, Provider Networks, and Health Benefit Coverage

Describe the differences between an open-panel and closed-panel HMO.

Describe what essential health benefits are why they may vary between states.

Identify and describe three different ways payer organizations are structured.

Identify and describe five elements of a typical payer-provider contract. Discuss some reasons why payers and providers would want to contract with each other.

Describe why provider credentialing is important. Who's responsible for credentialing providers, the documentation used in provider credentialing, and how credentials are verified.

Lesson 3: Provider Payment

A. Identify and describe the standardized code sets mandated by HIPAA, as well as commonly used code sets that aren't mandated. Explain why these code sets are important.

B. Describe what fee schedules and maximum allowable charges are. Explain what Relative Value Units and how these are used to determine reimbursement.

C. In an effort to enhance price transparency, Centers for Medicare and Medicaid Services (CMS) finalized policies in late 2019 that require hospitals to establish, update, and publicize a list of their standard charges for the items and services they provide. This includes:

* Gross charge of an item or service that's reflected on a hospital's chargemaster.

* Discounted cash price for individuals who pay with cash or a cash equivalent.

* Payer-specific negotiated charge for all third-party payers for an item or service.

* De-identified maximum negotiated charge, or the most expensive negotiated rate with a third-party payer for an item or service.

Explain why some stakeholders fear that this final rule could lead to price fixing.

 

Lesson 4: Utilization Management, Quality Management, and Case Management

Part A Describe different ways that utilization can be measured or projected for outpatient and inpatient services and how these can be used to determine payment rates set between payers and providers.

Part B Describe some reasons why it can be difficult to determine which drugs a health plan covers, and how this informs the creation of a formulary. Also describe the difference between an open and closed formulary.

Part C Describe the three interrelated categories of quality management activities.

Lesson 5: Sales, Governance, and Administration of Payer Organizations

Part A Describe the differences in responsibility held by the board compared to the management or leadership team of a health plan.

Part B Identify and describe four different mediums through which commercial health plans can sell their products.

Part C Describe the three categories of eligibility for coverage in the commercial market.

Part D Describe the process by which claims are processed and benefits are administered.

Lesson 6: Medicare and Medicaid; Health Insurance Laws and Regulations

Part A Describe the five major components that determine the payment rates of Medicare Advantage plans.

Part B Describe the different responsibilities in the regulatory oversight of Medicare Advantage plans from the federal, state, and corporate level.

Part C Describe how the payment rates of Medicaid managed care plans are determined.

Part D Identify and describe four ways that states oversee and regulate managed care organizations.

Part E Describe the federal government's role in in overseeing and regulating managed care organizations, and why this presents challenges when federal laws conflict with state laws.

 

   

MH684 Activity 4 Enrolling in a Medicare Plan

Activity 4: Enrolling in a Medicare Plan

You will be turning 64 next month and will qualify for Medicare. Over the last several years, you've been receiving advertisements and brochures from the AARP with information regarding options available for Medicare coverage. At first you were annoyed at the frequent reminders that you were growing older, but now you need to take a deeper dive into your coverage options. You're familiarizing yourself with the various parts of Medicare, Medicare Advantage Plans, and drug coverage options. You see that under Part D, you have the option of choosing a prescription drug plan (PDP) or a Medicare Advantage Prescription Drug Plan (MA-PD). You discover that several Medicare Advantage Plans are holding an open enrollment period soon. Star ratings are available for each plan, which you intend to use to guide your decision-making process. There's much to consider, but you want to enroll soon to protect yourself should any health problems arise in the near future.

A. Describe the differences between Medicare Parts A, B, C, and D including eligibility criteria for each.

B. Describe difference between a PDP and an MA-PD.

C. Describe what an open enrollment period means for Medicare Advantage plans and identify how these plans can accept enrollment requests.

D. Describe what Medicare Star ratings are, including the categories that are measured and the data sources typically used to generate ratings.

   

MH684 Activity 3

Activity 3

You're the chief operating officer of a Medicaid-managed care plan serving Medicaid and CHIP members in the southwest United States. You oversee operations of your health plan and assist your chief executive officer in defining and executing your health plan's strategy. Although the financial and accounting operations fall under the responsibility of the health plan's chief financial officer (CFO), you frequently meet with the CFO to identify initiatives that result in improved patient outcomes and reduced long-term costs. By federal law, your health plan is unable to recover the loss. So it's essential that patient care is rendered when appropriate. Your health plan covers a variety of services that span the care continuum and contract with all types of providers to ensure your members' needs are met. Coverage determinations are based on medical necessity and the use of evidence-based clinical guidelines, Utilization management (prospective, concurrent, and retrospective) is a particularly important area of health plan operations, as you want to ensure that care is only rendered when deemed appropriate, and this can help you manage your health plan's MLR.

You're particularly interested in promoting prevention and wellness and identifying ways to empower your members to take control of their health. However, many of your members have complex medical needs that require high levels of care. So you're faced with daily challenges of meeting your members' needs while also ensuring your plan is profitable.

A: Describe what MLR is and how exceeding the 85% limit can result in financial losses.

B: Describe what is meant by medical necessity and provide examples of excluded types of services.

C: Describe what evidence-based clinical guidelines are and how they are defined. Explain some limitations or challenges associated with determining evidence-based clinical guidelines.

D: Describe the difference between prospective, concurrent, and retrospective utilization management.

   

MH684 Activity 2 At-Risk Contracting

Activity 2: At-Risk Contracting

You are a practice manager for Accelerated Health (AH), a 25-physician hospitalist group that practices at St. James Hospital, a large hospital in an urban area. The hospital currently contracts with five hospitalist groups, but AH manages the largest share of the hospital's 1,500 monthly patient cases. AH has performed better than the other hospitalist groups in some of the hospital's key performance indicators, such as average length of stay (LOS). Currently, AH operates entirely on a fee-for-service model with no risk-based contracts. Their payer mix is 50% Medicare or Medicaid, 46% private insurance, and 4% self-pay. Referrals from primary care providers and other specialists drive most of their patient volume, and they continue to remain competitive in managing patient volumes at St. James. AH is only one of two hospitalist groups that covers the emergency department and also manages patients at a long-term acute care hospital. Managed care and capitation payments have yet to be widely adopted in your market, but there may be an opportunity for AH to be a first mover considering their payer mix and the patients they serve.

You're approached by Opti Health, an insurance payer, to manage their dual-eligible patients admitted to St. James under a capitated arrangement. Most of these patients have multiple comorbidities and require more intensive care, but Opti Health has a history of transferring its patients from other local hospitals to St. James Hospital. The initial contract would include a $600 payment per patient admission for an anticipated 20 patients per month. It would also require AH physicians to frequently meet with Opti Health case managers to ensure care is appropriately coordinated. All 25 of your hospitalists need to be in agreement before taking on any form of a risk-based contract.

A.   Identify what you perceive to be the key facts of the case. (20 points)

B.   Identify and describe key stakeholders or areas needing consideration. (20 points)

C.   Describe some reasons why you might recommend accepting the contract. (20 points)

D.   Describe some reasons why you might recommend rejecting the contract. (20 points)

E.   Identify your recommendation and explain why. (20 points) 

 

MH684 Activity 1 Overview of Managed Care

MH684 Activity 1: Overview of Managed Care

Blue cross blue shield association (BCBSA) consists of 26 independent and locally-operated health insurance companies. Blue Cross was created in 1929 to provide prepaid hospital care, and Blue Shield was established approximately a decade later to provide reimbursement for physician services. These separate entities merged in 1982 to form the BCBSA we know today. It comprised of publicly traded companies, such as Anthem, multi-state private companies, such as the Health Care Service Corporation and Highmark, and single-state or regional companies. BCBSA also operates health plans outside of the United States. The BCBSA has experience offering health insurance coverage options of all kinds including individual and group insurance, and also administers government entitlement programs, such as Medicare and Medicaid. Its health plans have come in many different forms, including health maintenance organizations (HMOs), preferred provider organizations (PPOs), point-of-service (POS) and consumer directed health plans (CDHPs), among others. A CDHP is a special form of a high deductible health plan coupled with a health saving account (HSA) to help individuals manage health care expenditures. BCBSA continues to grow and currently provides insurance coverage to nearly one out of every three Americans.

 

1. Describe the difference between individual and group insurance.

2. Describe the difference between Medicare and Medicaid, including who can qualify for coverage under each program.

3. Describe the difference between an HMO, PPO, POS and CDHP.

4. Describe an HSA, including how it can be used to manage personal health care expenditures.

 

 

MH684B Managed Health Care - Stand-Alone Project: Georgia's Child-Safe Program

STAND-ALONE PROJECT

MH684 Managed Health Care

 

Stand-Alone Project: Georgia's Child-Safe Program (300 points)

 

You should begin working on the Stand-Alone Project early in the course. Each assignment provides a benchmark for completing the Stand-Alone Project in a timely manner while working through the course. You will find this information in the "Stand-Alone Project Benchmark" section of each assignment.

You are a consultant with Standard Managed Care, Inc., which contracts with public entities to teach them how to deliver public services (publicly funded programs) using managed care techniques. The State of Georgia has contracted with Standard to design a managed care system for Georgia's Child-Safe program (fictional program). Child-Safe provides funding for Medicaid-eligible children with behavioral problems. You have been assigned the task of identifying ten (10) key issues with which the State of Georgia will need Standard's assistance to design a managed care structure for the Child-Safe program, along with an analysis for each of the key issues you identify. Then provide alternative solutions to resolve each issue, but state which solution you think is most appropriate for the Child-Safe program and why. Use at least five (5) sources, formatted in APA style. (300 points) (A 20-page, double-spaced, response is required.)

 20 pages with 7 references.