HSM 420 Threaded Discussions

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HSM 420 Threaded Discussions
Early models of health insurance in America were what we call “indemnity plans” or traditional health…

 

 

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HSM 420 Threaded Discussions

HSM 420 Threaded Discussions

Discussions Week 1-7 All Students Posts 457 Pages 

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Indemnity versus Managed Care and Managed Care Impacts Discussions Week 1 All Students Posts 60 Pages

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Indemnity Versus Managed Care – 33 Pages

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Early models of health insurance in America were what we call “indemnity plans” or traditional health insurance plans. What is meant by an indemnity plan, and how is managed care different from traditional indemnity insurance?…

Why was managed care created? Was indemnity not suitable?  With the Affordable Care Act, are we still concerned with managed care backlash?  Managed care has allowed many individuals to receive care that they were unable to receive prior to its existence.  Having said that, it is also noted that managed care has changed throughout the years.  Services have been streamlined, coverage has been minimized.  Many of the affordable managed care plans do not offer the needed coverage.  How has the Affordable Care Act changed this?  What are the effects of healthcare reform on indemnity insurance? How has managed care changed from its time of inception?  How has the Affordable Care Act changed indemnity plans?  Will they continue to be an option?  What are some of the financial incentives offered by managed care plans?  What incentives offered for indemnity plans?  What can be done to stop the rising costs?…

Managed Care Impacts – 27 Pages

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There can be no doubt that managed care has impacted everyone involved with healthcare delivery in America. What do you see as some of the most significant impacts of managed care for patients?…

When choosing employer sponsored healthcare plans, there are limits to our choices.  Do employees have as many provider options as managed care intended?  Many employees had their hours reduced so that the employer would not have to offer health insurance as mandated by law.  What can be done to address this issue?  With managed care, is our access limited?  Should we not have access to quality care?  If we have long waiting periods to see a physician are managed care’s objectives being met?  Do you think that these provisions have assisted in controlling healthcare costs?  Do you think that they are too strict?  How has healthcare reform affected your managed care choices?  With managed care, is our access limited?  Should we not have access to quality care?  If we have long waiting periods to see a physician are managed care’s objectives being met?…

Provider Networks and Legal Issues in Provider Contracting Discussions Week 2 All Students Posts 63 Pages

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Provider Networks – 31 Pages

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Why do managed care organizations seek to establish a provider network? What are the primary reasons for contracting with providers?  Can an MCO survive without a provider network?…

In a small town, how large can the provider network be?  It is often stated that the small town insured individuals complain about having to drive many miles to receive care. What is the average mileage an individual has to drive to receive care?  In many areas, patients have to travel 30 miles or more to receive basic care.  What can MCOs do to entice providers to practice in such areas?  You stated that purpose of managed care is to provide health care services.  To whom are these services to be provided?  Healthcare should be regarded as a right; however, it is being managed as a privilege.  Managed care was to make healthcare affordable, but unfortunately, the premiums continue to rise.  How are we to receive what is a right if we are unable to afford it? With knowing that an MCO cannot survive without a provider network, does this make the providers the authority?  Are they able to dictate reimbursement rates?  Since MCOs control costs, do providers feel the need to avoid certain testing or services to ensure that they remain compliant with the MCO?  Are providers foregoing quality care for compliance?  With an MCO, who benefits more a provider network or the patients?…

HSM 420 Threaded Discussions

Legal Issues in Provider Contracting – 32 Pages

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Describe and discuss the key issues associated with provider payment that should be addressed in any managed care contract.  The way that providers are reimbursed has been simplified.  Why are some providers having issues with receiving payment?…

This form of reimbursement seems to be simple enough.  However, how are services administered outside of the bundle requirements paid?  Are providers allowed to bill additional services?  Overbilling/fraudulent billing is one of the major contributors to our healthcare deficit.  What more can be done to prevent such acts?  What is the grace period for errors?  Are providers being penalized for these errors?  Can you tell us what prompted the implementation of the ICD-10 codes?  Do you think that we should revert back to more of an indemnity environment?  Should we allow providers to determine pricing?  What are some examples of medical records being compromised?  What are the consequences?  What are more incentives that can be offered to encourage individuals to seek preventative care?…

Utilization Management and Case Management versus Disease Management Discussions Week 3 All Students Posts 67 Pages

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Utilization Management – 33 Pages

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What are the primary categories of utilization management (UM)? How does UM determine medical necessity through the use of evidence-based guidelines?  What do the categories used in utilization management mean in laymen’s terms?….

If physicians are in charge of the care of the patient, why should they not be in charge of which services and how often the services should be rendered?  How does this apply to what is taking place in healthcare today? How has the Affordable Care Act impacted utilization management?  What is your analysis of the information that you provided?  Who is responsible for ensuring that all providers are following the medical guidelines as they deliver care?  Can a provider appeal a denial for services deemed as unnecessary if he/she feels that the service is needed?  If so, how long is the process?  If not, what are the providers options?  Is utilization management used in indemnity healthcare plans?  Is medical necessity a priority with indemnity plans?  What is the role of the provider?  If they deem that a service is medically necessary but it does not meet the UM standards will the service be covered?…

Case Management Versus Disease Management – 34 Pages

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What are the key differences between conventional case management and disease management? Provide some examples of diseases that seem to benefit from a disease management model of care.  What is case management?  What is disease management?  How would case management differ in an urban patient with kidney issues and a rural patient with kidney issues?….

What happens if the patient needs to deviate from the standard?  Will the services be covered?  Since the inception of the Affordable Care Act, have the standard services that are covered by insurance companies changed?  Has the Affordable Care Act changed the way that cases are serviced?  Has it changed the way that diseases are managed?  Which states or areas use this form of integrated health care services?  Although, payers cannot deny coverage to those with pre-existing conditions, are insurance companies allowed to charge more for pre-existing conditions?  Do most disease management plans become case management plans?  What do I mean by this?  Which is more costly, disease management or case management? What are the similarities of case management and disease management?…

Managed Care Pharmacy Benefits and Managed Behavioral Healthcare Discussions Week 4 All Students Posts 58 Pages

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Managed Care Pharmacy Benefits – 31 Pages

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What are the most important elements of a managed care pharmacy benefit program? And how are patient prescription benefits typically different under managed care?  Pharmacy benefits is a controversial topic within managed care.  As a patient, what do you want?  How often do pharmacists recommend certain drugs to providers?  Is this recommendation for costs control or quality products?…

With healthcare reform are we seeing more coverage for prescriptions?  How has reform changed pharmacy benefits? What is the protocol is the brand name is not covered, but it has been determined that your body responds better to the brand?  Are concessions made for the patient?  Who is responsible when a patient is prescribed medications that should not be taken together?  The provider?  The pharmacist?  With healthcare reform are we seeing more coverage for prescriptions?  How has reform changed pharmacy benefits?  Although the generic drugs supposedly contain the same ingredients, the effect is often not as effective.  Why do you think that this is?…

HSM 420 Threaded Discussions

Managed Behavioral Healthcare – 27 Pages

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What factors surrounding behavioral health create special challenges and special considerations for managed care programs? How is managed behavioral healthcare different from managed acute medical or managed acute surgical care?  The need for behavioral healthcare coverage is ever-growing in this country.  What is the problem with providing adequate coverage?  Do you think that if patients stopped using the ER as a doctor’s office and used it for emergencies only that there would be adequate staff?…

Why is it that society deems behavioral health as taboo?  Because of this, many fail to seek help.  What can be done to change the perception of behavioral health?  What can managed care plans and the Affordable Care Act do to make managing mental health less challenging and more efficient?  If we are increasing access, we need to increase providers.  What can be done to entice individuals to seek a career in behavioral health?  Does the fact that the benefits are minimal which means receiving payment may be difficult have anything to do with the lack of providers?…

Managed Care Accreditation and Managed Care Marketing Discussions Week 5 All Students Posts 64 Pages

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Managed Care Accreditation – 36 Pages

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Discuss the main elements of the managed care accreditation process. For each main element, explain why it is important.  Are these steps adequate?  Should more be done?  There are so many elements that must be monitored.  If healthcare facilities were not held accountable for delivering these elements in an efficient manner, quality care would not be delivered.  For reimbursement of Medicare claims must the facility be accredited?…

What are some of the common standards mandated by NCQA? Although there are several standards, all facilities are not accredited.  What do non-accredited facilities do to compete with accredited facilities? Is your local hospital or healthcare facility NCQA accredited?  What information on your local facility can you find?  Were you able to find out why certain areas are accredited by NCQA and some are not?  What are some of the common standards mandated by several accreditation organizations? Although accreditation is not mandatory, what is the success rate of hospitals that are not accredited?  Are there insurance plans that require accreditation? If a facility is not accredited, what does this mean for the facility?  Are they eligible for reimbursement from government programs such as Medicare and Medicaid?…

Managed Care Marketing – 28 Pages

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Discuss how managed care sales and marketing have evolved over recent decades, and how these may possibly evolve over the decades ahead.  Does healthcare marketing vary based on location?  With the Affordable Care Act, have the number of insured in rural areas increased?…

With universal healthcare will the marketing still differ?  With marketing varying based on location, does this mean that pricing varies based on location as well? Why is the healthcare more expensive in Maryland than it is in Georgia?  Does this mean that the quality is better in Maryland than it is in Georgia?  Does medical underwriting differ based on location?  Does where you live determine your healthcare rate?  How do hospitals advertise quality?  Which organization measures quality healthcare?  As a patient, we are to understand this information.  We need to know the equivalence of high quality.  Which hospital has the best quality?  Which provider provides the best quality?  Patients need to educate themselves with this type of information.  How has the Patient Protection and Affordable Care Act affected the way that managed care is marketed?…

Fraud and Abuse and Underwriting and Rating Discussions Week 6 All Students Posts 77 Pages

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Fraud and Abuse – 44 Pages

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Discuss fraud and abuse in healthcare. Provide at least three specific examples of fraudulent practices that have taken place in U.S. healthcare, and describe ways to prevent these in our modern healthcare environment….

Imagine how many other deceased patients there are that have been billed for services that they did not receive.  Many families will just ignore the bill and the provider will receive payment.  Monitoring fraud and abuse needs to be a priority.  Decreasing such acts will save the country millions.  What are some of the consequences that are given to providers who abuse the system or commit fraud?  What are Medicaid and Medicare agencies doing to prevent this type of fraud?  Does fraudulent behavior of employees stealing time contribute to growing healthcare expenditure?  Why or why not? In recent years, several companies have experienced a breach in their security and their patrons have been affected.  Within a healthcare facility, if a patient’s private information is stolen, who is responsible?  If it results in monetary damage such as credit cards being opened in the victim’s name, will the healthcare facility cover the damages?  Are there cases of providers serving jail time for fraud or abuse?  Are fraud and abuse different?  Are the penalties different for fraud than for abuse?…

HSM 420 Threaded Discussions

Underwriting and Rating – 33 Pages

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Explain the difference between underwriting and rating. What are the key elements that typically go into rate development formulas? I agree that underwriters must remain knowledgeable of all new laws.  This role involves continuous training.  What do you think is the most stressful about this job?  Do you think that it is difficult for the underwriter to keep emotion out of his/her decision?…

What can clients do if they do not agree with the underwriting findings? Do you think that lifestyle should be considered when determining the cost of coverage?  Within a workplace, should I have to pay the same amount as a smoker? With healthcare reform were changes made to the underwriting and rating process? Which health risk has the highest rating?  Which diagnosis can generate the highest premium? Does the Affordable Care Act look at health history to determine the rate the insured will be charged?  Are the premiums the same for everyone in a particular age group? If there are employees with pre existing conditions how does their rating affect others?  Should all employees have to pay for the choices of others?  Should I have to pay for a smoker?  Do you think that this type pricing determination is fair?  Is there a better way to rate patients? Some think that health status should not be a factor when determining rates.  I am not sure that I like the idea of health status not being a factor when determining rates.  Does this mean that non Affordable Healthcare plans will charge higher premiums to offset the plans within the Affordable Care Act?…

State and Federal Regulation and Patient Protection and Affordable Care Act Discussions Week 7 All Students Posts 68 Pages

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State and Federal Regulation – 34 Pages

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What are the most critical components of state regulation for managed care organizations? And which federal regulations also bring specific requirements for the operation of such entities? Discuss state and federal regulation of MCOs. Do you think that there are enough regulations for MCOs? …

What are the most critical components of state regulation?  What are a few of the mandates? What are some of the unique state regulations mandated in your state?  Why was this law developed? What are the healthcare regulations mandated in your state? What are some of the federal regulations that take precedence over state regulations?  Since MCOs cannot deny coverage for preexisting conditions, do they make the premiums of those with preexisting conditions higher?…

Patient Protection and Affordable Care Act – 34 Pages

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Study the provisions of the Patient Protection and Affordable Care Act (PPACA) in your textbook. What will be the primary impacts of PPACA on managed care organizations. Consider both positive and negative impacts in your answer. Why was the PPACA developed?…

How many individuals are now insured due to PPACA?  What are some of the disadvantages to ACA?

Primary impacts by the PPACA is changes to physician reimbursement.  Currently, physicians work under a fee-for-service system, in which physicians will treat and bill for a patient’s care, generally through an insurance company and payment amounts are dictated by the Medicare Physician Fee Schedule.  The PPACA will change the current formula for physician payments by establishing a value based payment modifier that provides for differential payment based on the quality of care furnished…

HSM 420 Threaded Discussions

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