HSM 546 Health Insurance Management Entire Course NEW Keller
HSM 546 Health Insurance Management Entire Course NEW Keller

HSM 546 Health Insurance Management Entire Course NEW Keller

$85.00

HSM 546 Health Insurance Management Entire Course NEW Keller
You Decide Week 2, 5, 6 | Patient Protection and Affordability Act Week 3 | Midterm Exam| Course Project Week 7| Discussions Week  1-7| Final Exam

Description

HSM 546 Health Insurance Management Entire Course NEW Keller

HSM 546 Health Insurance Management Entire Course NEW Keller

A+

HSM 546 Health Insurance and Management Entire Course NEW Keller

You Decide Week 2, 5, 6 | Patient Protection and Affordability Act Week 3 | Midterm Exam| Course Project Week 7| Discussions Week  1-7| Final Exam

HSM 546 CEO Southside HMO You Decide Week 2 Keller

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Scenario/Summary

You are the chief executive officer of Southside HMO, which serves 495,000 members throughout the eastern region of the United States. It has come to your attention that several members or patients who participate in your plan have filed a complaint that your HMO plan does not provide quality healthcare delivery. Several patients have been denied healthcare services to see specialists to whom they were referred by their primary care providers.

Your Role/Assignment

The board of directors has asked that you provide a 750-word report detailing your strategies and recommendations to investigate the complaints and to identify strategies to ensure that quality management initiatives are in place to make sure that quality healthcare services are provided to all members. The strategies and recommendations should be as specific as possible and include the resources needed for implementation. Your primary text and journal and website research must be used as a reference to support your analysis.

Key Players

Review the points of view of the following people to obtain further insights on this assignment….

Preview:

The CEO of Southside HMO, which serves 495,000 members in the Eastern region of the United States, has received various complaints from plan holders, claiming that they do not receive quality healthcare services and that some of them are….

HSM 546 Patient Protection and Affordability Act Week 3 Keller

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Use the DeVry-Keller Online Library to find a research article (no older than 2009) related to the Patient Protection and Affordability Act. Discuss physician practice behaviors related to managed healthcare and the future of managed care under healthcare reform.

Your written paper should be 750 words, double-spaced, and in APA style. Your primary text and the journal or website research article must be used as references to support your analysis paper. Use at least three references.

Preview:

Enacted on March 3, 2010, the Patient Protection and Affordability Act enabled 95 percent of America’s legal population (32 million-50 million more Americans) to obtain healthcare insurance (Amadeo, 2018).  Also known as…

HSM 546 Midterm Exam Health Insurance and Management Keller

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(TCO A) Describe quality management tools used to assess the quality of managed care plans.

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Some of the tools used are utilization management and outpatient management, and the management of inpatient and…

(TCO B) Compare and contrast open-panel and closed-panel HMOs.

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Open-panel HMO is a type of conventional medical insurance where the patient pays a fixed fee to the HMO but…

(TCO C) Discuss open-panel managed care plans and provider networks.

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In open-panel managed care plans, insured members are allowed to access physicians outside the network or panel…

(TCO D) Define pay-for-performance (P4P), and explain how P4P is used to improve the quality of healthcare delivery.

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Pay for performance is a payment model where providers are paid for the medical services they render based on…

(TCO D) Define capitation and how capitation is calculated for prepayment.

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Managed care organizations use capitation payments to control healthcare costs. They control the use of healthcare….

HSM 546 Pay-for-Performance Written Assignment Week 5 Keller

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Go to the website CMS.gov 

Click on one of the articles, and analyze pay for performance quality and incentives in hospitals, nursing homes, or provider offices and describe the performance standards and scoring methods.

Your written paper should be a minimum of 750 words, double-spaced, and in APA style. Your primary text and the journal or website research article must be used as references to support your analysis paper. You must use at least three professional references.

Preview:

In general, pay-for-performance refers to “initiatives aimed at improving the quality, efficiency, and overall value of health care” (Andrus, 2015).  Also termed as alternative payment, value-based payment, and pay-for-quality, its…

HSM 546 Regional Hospital You Decide Week 6 Keller

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Scenario/Summary

You are the chief executive officer of Regional Hospital, which serves a community of 875,000 people throughout the Charlotte Mecklenburg area of North Carolina. In order to improve health outcomes and reduce costs, you are reviewing proposals to contract with a disease management company. Several disease management companies have submitted their proposals to you for review.

Your Role/Assignment

The board of directors has asked that you provide a 750-word report detailing your strategies and recommendations to contract with a disease management company in order to reduce utilization costs and to improve patient health outcomes. Your report should outline the specific interventions and model that will be used by Regional Hospital. Your presentation should also explain cost projections and savings over a 10-year period. The strategies and recommendations should be as specific as possible and include the resources needed for implementation. Your primary text and journal and website research must be used as references to support your analysis.

Category Points % Description
Content 10 20 Content is excellent, completely consistent, and appropriate

for audience and purpose; content contains excellent internal

integrity; detail is rich and specific.

Organization 10 20 Organization is excellent; ideas are clear and arranged

logically and the transitions are smooth; there are no flaws in

logic.

Design and Format 10 20 Document format is excellent with strong visual impact,

design, and format.

Style and Readability 10 20 Readability is excellent with strong attention to audience,

appropriate tone and style, and good transitional language;

there is good use of figurative language.

Grammar and References 10 20 Grammar, referencing, punctuation, mechanics, and usage

are correct and idiomatic; paper is consistent with Standard American English; paper demonstrates competent use of mechanics.

Total 50 100 A quality paper will meet or exceed all of the above requirements.

Preview:

As the CEO of Regional Hospital, which serves a community of 875,000 people, I am reviewing proposals to contract a disease management company.  For this, I must consider the various factors for choosing a disease management company.  I must also determine….

HSM 546 Healthcare Fraud Course Project Week 7 Keller

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This Course Project gives you the opportunity to select a managed healthcare organization or an integrated delivery system that currently exists in our healthcare system and analyze the positive and negative aspects of the integrated delivery system or managed healthcare organization. The paper should critically analyze the issues related to the topic and identify key strategies for improvement. In order to meet the project requirements, it is important to identify an issue or problem within the integrated delivery system or managed healthcare organization. Please analyze and review the grading rubric to understand why this is important. Peer-reviewed references are required for this paper. Don’t overlook the Keller Library as an important source of information for your paper. The paper should include 8–10 references in APA style and format.

See a more detailed grading rubric below.

The length of the final paper should be approximately 8–10 pages, double-spaced in MS Word, including a title page (APA style), introduction, APA level-one headings throughout, a conclusion, and a reference page.

Example Course Project Topics

Describe a managed care organization or integrated delivery system, and discuss the positive and negative aspects related to healthcare quality, costs, and access to healthcare.

  • Choose a closed- or open-panel health maintenance organization and discuss a specific model, such as a direct contact model, group model, or staff model.
  • Evaluate healthcare quality and cost related to health maintenance organizations.
  • Choose an integrated healthcare delivery system, such as a physician group practice, and discuss the benefits and legal structure for group practices.
  • Evaluate physician hospital organizations and how the organizations contract with insurance companies.
  • Discuss healthcare fraud in relationship to managed healthcare and provide examples.
  • Evaluate quality management of healthcare in managed healthcare, utilization, and cost management and provide examples.
  • Discuss the federal and state regulations for managed care and integrated delivery systems and explain how trends have changed in the past 2 years.
  • Evaluate challenges to provide healthcare services to the newly insured population through marketplace.gov health insurance exchanges.

Grading Rubric

  • Introduce the issue.
  • Define the problem.
  • Search the literature.
  • Analyze the problem.
  • Offer possible solutions.
  • Develop an implementation plan.
  • Justify why and how your solution will solve the identified problem.

Preview:

The U.S. healthcare system incurs an estimate of $700 billion in losses due to abuse, waste, and fraud in the healthcare system (Thornton et al., 2013).  According to the US Department of Health and Human Services, fraud refers to “the intentional deception or misrepresentation…

HSM 546 Threaded Discussions Week 1-7 All Posts 624 Pages Keller

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HSM 546 Managed Care and Current Trends and Quality and Access Discussions Week 1 All Posts 88 Pages Keller

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HSM 546 Managed Care and Current Trends Discussions 1 Week 1 All Posts 45 Pages Keller

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In your own words, define managed care and discuss how managed care impacts healthcare delivery under healthcare reform.  Are all these mergers and acquisitions a good thing?  Will monopoly be the result of all these mergers and acquisitions?  But what if the merger goes through and the new organization fails?  Which organization would you prefer i.e. HMO, PPO?  What does HMO stand for?  Do all diagnostic procedures require pre-certification?  What happens if I want to try alternative forms of medicine?…

HSM 546 Quality and Access Discussions 2 Week 1 All Posts 43 Pages Keller

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In your own words, explain the importance of why managed care plans must provide quality healthcare.  In this thread we will discuss TCO A and additionally look at some fundamental characteristics of risk.  Every day we are reminded of a chance of loss – so what is your definition of risk?  We face risk and accept a certain amount of risk everyday but should we as a society should assume others’ risk?  Why should I have to pay for the medical costs of smokers when they assumed the risks and I don’t smoke?  We are discussing quality healthcare but what is the “quality” ?  What is benchmarking and which definition do you find more compelling?…

HSM 546 Health Maintenance Organizations and Governance of Managed Care Organizations Discussions Week 2 All Posts 81 Pages Keller

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HSM 546 Health Maintenance Organizations Discussions 1 Week 2 All Posts 42 Pages Keller

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Let’s begin this thread focusing on HMOs. When I think about HMOs, the first name that pops into my head is Kaiser.  The primary function of an HMO is the efficient management of healthcare resources. A doctor’s primary function is the medical care of the individual patients. So, how can this relationship which appears to be at odds with each other sometimes, provide quality healthcare for patients especially in a closed panel HMO structure?  HMOs are often vilified for denying benefits but surely HMOs provide some benefit to society. Any takers on this one? Who will speak for the HMO?  If you could be the CEO of one or the other, which would you choose and why?  Now let’s think about integrated healthcare delivery systems.  What are some examples?

HSM 546 Governance of Managed Care Organizations Discussions 2 Week 2 All Posts 39 Pages Keller

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This week we discuss TCO B.  Does ownership of the HMO affect management strategies?  What about utilization outcomes?  Do members of the board owe a fiduciary duty to members of the organization? But before we can answer this question what is a fiduciary duty?  Ever wonder who are members of boards? I chose HCA which is a Nashville based company.  Find anything interesting to share?  So if a member breached one of these duties, could the member be held personally liable? Let’s look at duty of care.  Ever hear of D&O?…

HSM 546 Provider Networks and Federal Regulations Discussions Week 3 All Posts 92 Pages Keller

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HSM 546 Provider Networks Discussions 1 Week 3 All Posts 44 Pages Keller

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In your own words, explain contracting approaches for physicians and hospitals under managed care plans.  This week we discuss TCO C and for our first main question we look at provider networks. Ever heard of “narrow network”? What is this?  The main question this week talks about contracts and the text poses the question of why contract? So, now please consider – you are the business manager for a large medical group and it is time to renegotiate the contract with an HMO. What details would you want to look at more closely this time?  Contracts of adhesion. What is this and how might the business manager avoid such a contract?…

HSM 546 Federal Regulations Discussions 2 Week 3 All Posts 47 Pages Keller

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In your own words, discuss one of the federal regulations and acts to regulate health maintenance organization plans.  It will be interesting to see what happens in 2019. In Tennessee the ACA has caused a reduction in the choices of insurance companies providing products in some counties. My sister lives in Davidson County (Nashville) and must buy individual coverage. BCBS has pulled out of Davidson County for individual coverage. So she has had to buy  Oscar insurance which was founded in 2012. Comments?

Recall the serial killer who was found by the DNA of a family member? Does this raise privacy issues?  Every state now has a law requiring MCOs to offer their members internal grievance and appeals procedures. Do you know what your state law includes?…

HSM 546 Provider Payment and Claims and Benefits Discussions Week 4 All Posts 88 Pages Keller

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HSM 546 Provider Payment Discussions 1 Week 4 All Posts 41 Pages Keller

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Discuss the challenges and benefits of pay for performance under managed care plans.  Ever heard of the logic game – The Prisoner’s Dilemma?  Many of the private practices here have sold to Vanderbilt or St. Thomas. The hospital then provides management services to the practice.  But here’s a question…. if MCOs employ doctors and nurses, why are these types of claims denied?  Doctors know that some patients will not follow their advice and of course should not be penalized. Which is why documentation by the doctor is so vital.  Thoughts?

You have just become the manager for WECARE a managed health care plan. The manager who had the position before you did not do a good job. In fact, the company has been losing members as well as contracted physicians. Your first course of action is to address member services.

How will you address WECARE’s problems in this area?…

HSM 546 Claims and Benefits Discussions 2 Week 4 All Posts 47 Pages Keller

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Describe the current challenges of claims capabilities, including ICD-10-CM.  There are five basic purposes for the claims and benefits administration department:
-plan contract administration
-benefits administration
-medical management policy administration
-member and provider service
-liability protection

Which one is the most important?  Can a plan come into being or even exist without contracts?  The contract is the foundation of the business and defines the obligation of the parties. So how does the contract open the MCO to liability?  Should insurance companies be more forthcoming?

You are the administrator of a large hospital. This is the only hospital in the area and it needs an anesthesia group. But the group in the area is not wanting to contract with the hospital and accept the lower rate.What will you do?…

HSM 546 Legal Issues and Fraud and Abuse Discussions Week 5 All Posts 91 Pages Keller

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HSM 546 Legal Issues Discussions 1 Week 5 All Posts 43 Pages Keller

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Discuss the clauses and provisions that should be included in provider contracts.  What is the function of contract law? Describe the role of state government in the regulation of managed care.  You’ve heard the saying “that contract is not worth the paper it’s printed on.” A contract is a memorialized agreement between the parties. The real value of a contract comes into play when it is challenged in court.  The elements of a contract include: Mutual Assent -Offer and acceptance, Consideration, Intent…

HSM 546 Fraud and Abuse Discussions 2 Week 5 All Posts 48 Pages Keller

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What steps should be taken to mitigate exposure and liability when the federal government shows up to audit a healthcare organization?  There are a number of civil and criminal statutes that deal with false claims. The Medicare and Medicaid fraud and abuse law; the mail fraud statute 18 U.S.C.A. §1341; laws prohibiting persons from knowingly making or presenting false or fraudulent claims to the U.S. government, 18 U.S.C.A. §287; statutes prohibiting the making of false or fraudulent statement or representation, 18 U.S.C.A. § 1001; and wire fraud, 18 U.S.C.A. § 1343; Secondary offenses such as aiding and abetting, 18 U.S.C.A. § 2, conspiracy, 18 U.S.C.A. § 371; and theft of government property, 18 U.S.C.A. § 1961-68 are also some possible charges. And let’s not forget the RICO statutes.  So you can see that the government does not take fraud and abuse lightly.  So what can you do before an audit to reduce liability for your organization?  Some folks have mentioned a compliance officer.  What would be the duties of this compliance officer?  The main question is titled fraud and abuse but there is a difference – what is that difference?

HSM 546 Utilization Review and Medicare Advantage Plans and Medicaid Plans Discussions Week 6 All Posts 92 Pages Keller

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HSM 546 Utilization Review Discussions 1 Week 6 All Posts 47 Pages Keller

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Describe the three categories of utilization review and explain why utilization review is the framework for utilization management.  And what happens when services are denied? Could the numbers get in the way?   Precertification is common for many medical services but what happens when services are rendered and then the insurance company UR denies the service?  You have taken charge of your health. So DM for you is at the personal level.  Now, how might your case fit into your insurance company’s DM program?  Referring back to the NY law of mandatory reporting for A1c., when does DM  interfere with a patient’s privacy?…

HSM 546 Medicare Advantage Plans and Medicaid Plans Discussions 2 Week 6 All Posts 45 Pages Keller

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Compare and contrast Medicare Advantage plans and Medicaid plans.  What are these plans?  What are some differences between Original Medicare and Medicare Advantage Plans?  Typically Medicaid pays even less than Medicare – so why would a physician choose to participate in that program?  Do you know what your state’s requirements are for Medicaid eligibility?…

HSM 546 State Regulations of Managed Care Plans and Federal Regulations of Managed Care Plans Discussions Week 7 All Posts 92 Pages Keller

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HSM 546 State Regulations of Managed Care Plans Discussions 1 Week 7 All Posts 47 Pages Keller

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Outline the insurance market rules and rating factors and how HIPAA impacts the rating factors.

How does the Supreme Court decision of Paul v. Virginia, 1869 and United States v. South-Eastern Underwriters Assoc., 1944 apply to the McCarren-Ferguson Act of 1945?  What are some benefits of states having the power of regulation over healthcare insurance?

Innovation at the state level could mean experimentation and if the experiment fails then only that state is affected rather than the entire country. Thoughts?  Now let’s look at some of the disadvantages of state regulation. What might these include?…

HSM 546 Federal Regulations of Managed Care Plans Discussions 2 Week 7 All Posts 45 Pages Keller

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Discuss the federal agencies that are responsible for the oversight of HMOs, and discuss when federal regulations or state regulations would apply to situations, such as HIPAA privacy standards.  To begin this week we look at the HIPAA rule.  So what “first” did HIPAA achieve?  Until HIPAA virtually no federal rules existed to protect the privacy of health information and guarantee patient access to such information. How had patient privacy been addressed before HIPAA?

Rules protecting patient privacy were within the domain of each state.  Virtually every state had one or more laws to safeguard privacy and these varied significantly from state to state.   Why is privacy so important and are the costs of regulation to ensure privacy worth it?…

HSM 546 Final Exam Keller

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(COs A, B, and D) Capitation is defined as _____.

Prepayment for services on a fixed, per member, per month basis

Fee-for-service, including withhold provisions

Performance based compensation system

Stop-loss reinsurance provisions

(COs A, B, and D) Which federal law has established specific, enforceable regulations to help ensure the privacy and confidentiality of individual health information?

OCR

HEDIS
HIPPA
EMTALA

(COs A, B, D and G) The fee for service (FFS) payment method may encourage _____.

Unbundling

Upcoding

Churning

All of the above

(COs A, B, C, D, E, F, G, & H) What is disease management?

Disease management refers to a system of coordinated health care communications and interventions for populations with conditions where…

COs A, B, C, D, E, F, G, & H) Explain what integrated delivery systems are, and provide some examples.

The concept of integrated delivery system involves placing all required levels of care within a single integrated…

(TCOs A, B, and D) Managed health care is best described as _____.

An insurance company that provides health services

A broad and constantly changing array of health plans that attempt to manage both cost and quality of care

An inexpensive form of payment for health services

(TCOs A, B, and D) Which type of case is least likely to benefit from case management?

Cancer

AIDS

Normal vaginal delivery

All of the above

(TCOs A, B, and D) Which of the following organizations has developed accreditation programs for managed care organizations?

NCQA

URAC

AAAHC

A and B

All of the above

(TCOs A, B, and D) The integral components of managed care are _____.

Wellness and prevention

Primary-care orientation

Utilization management

Wellness, prevention, and utilization management

All of the above

(TCOs A, B, and D) The purpose of ERISA is to _____.

Ensure that all individuals receive emergency medical care, regardless of their ability to pay for services

Ensure the continuation of coverage for individuals who may lose health insurance due to termination of their employment

To protect workers in employee insurance plans and their beneficiaries by the requirement of disclosure and reporting financial and other information to workers and their beneficiaries

All of the above

(TCOs A, B, and D) Fees for services are generally determined by using _____.

Quality indicator measures

HMO insurance fee schedules

HMO insurance fee schedules

The type of services provided

(TCO A) Describe the key steps in developing a modern quality management program.

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The first step to developing a modern quality management program is to identify the scope of the problem and estimate the benefits of…

(TCO H) Explain what a gag clause is, and why it is important in managed care plans.

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The gag clause is a legislation clause that prohibits physicians from frankly and openly discussing all treatment options – whether covered or…

(TCO C) Discuss the purpose of the Patient Protection and Affordable Care Act.

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The Patient Protection and Affordable Care Act, which was signed into law on March 2010, was intended to extend coverage to the millions of Americans who are…

(TCO E) Describe the role of state government in the regulation of managed care.

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While the federal government regulates managed care and health plans sponsored by private-sector employers, the state governments regulate the….

(TCO F) Discuss the role of the primary care physician in utilization management.

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The primary care physicians play a big role in utilization management because they can greatly influence how much care a patient receives. Since a primary care…

(COs A, B, C, D, E, F, G, & H) What is disease management?

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Disease management refers to a system of coordinated health care communications and interventions for populations with conditions where…

(COs A, B, C, D, E, F, G, & H) Explain what integrated delivery systems are, and provide some examples.

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The concept of integrated delivery system involves placing all required levels of care within a single integrated…

(TCO H) Discuss the three broad types of structure for managed care plans.

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The three broad types of structure for managed care plans are health maintenance organizations (HMOs), Point of Service (PS), and…

(TCO C) Explain the relationship between provider networks, managed care plans, and plan members. What is the importance of this relationship?

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Managed care plans are a type of health insurance, which enters into contract with medical facilities and healthcare providers…

(COs D and E) Explain the HMO Act of 1973 and how the act changed the government’s role in managed care.

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The HMO Act of 1973 is a US federal law enacted under President Richard Nixon’s administration. It intends to encourage…

(COs G and H) Discuss the categories that fall under the state requirements for the health insurance market, and the laws that govern health insurance markets. What is it and why is it important?

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The categories that fall under the state requirements for the health insurance market are HMOs, PPOs, and POS plans. HMOs…