HSM420 Managed Care Health Insurance


HSM420 Managed Care Health Insurance
This HSM 420 Course Project provides you with an opportunity to select one important health insurance…


HSM420 Managed Care Health Insurance

HSM420 Managed Care Health Insurance

A+ Course Project Week 2, 5, 7 | Midterm Exam | Quiz Week 6 | Discussions Week 1-7

Fraud and Abuse in Managed Care Course Project Week 2, 5, and 7 


This HSM 420 Course Project provides you with an opportunity to select one important health insurance, managed care, or healthcare reform challenge (or problem to solve) and analyze it in greater depth in a written format.

The paper should critically analyze the issues related to your topic within the context of the current healthcare environment, and also considering future directions in U.S. medical care. Web references, books, and professional journal articles should be considered as references. And don’t overlook the DeVry Online Library as an important source of information for your paper!


  • Your Course Project should be 7–10 pages in length, with 10-point font, and double-spaced. Include a cover page, table of contents, introduction, body of the report, summary/conclusion, and works cited.
  • Even though this is not a scientific writing assignment, and is mostly creative in nature, references are still very important. At least six authoritative outside references are required. These should be listed on the last page, titled Works Cited.
  • Appropriate citations are required.
  • All DeVry University policies are in effect, including the plagiarism policy.
  • Papers are due during Week 7 of this course.
  • Any questions about this paper may be discussed in the weekly Q & A Discussion topic.
  • This Course Project is worth 320 total points and will be graded on quality of research topic, quality of paper information, use of citations, grammar, and sentence structure.


The Course Project is worth 370 points (50 for the Course Project topic, 100 for the Course Project outline, 170 for the final Course Project, and 50 for the Peer Review).

Topic (Week 2): 50 points It is expected that you will provide a focused topic, including a statement of the key challenges or problems currently associated with the topic in America.

Outline (Week 5): 100 points

It is expected that the outline be submitted in a formal outline format as demonstrated below. Your outline should show enough detail to demonstrate that you have begun thinking about the organization of your paper and the research required into the topic. After your outline, please submit a listing of the sources you have already identified for your paper.

  1. Each Roman numeral should be a main section of the paper.
    1. Subpoint
      1. Details of Subpoint
        1. Details Related to the Subpoint
      2. Subpoint

HSM420 Managed Care Health Insurance

Final Course Project (Week 7): 170 points

It is expected that the final version of your Course Project will be 7–10 pages in length, with 6–8 sources identified.

APA in-text citation is required in addition to listing all of your sources on a works cited page at the end of the document. Your grade will be affected if you do not cite or identify your sources correctly.

Topic Selection Week 2 (50 points)

Fraud and Abuse in Managed Care


It is expected that you will provide a focused topic, including a statement of the key challenges or problems currently associated with the topic in America.


In 1993, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) established a program that would manage and control fraud and abuse cases in the United States called the Health Care Fraud and Abuse Control Program (HCFAC).  However, healthcare fraud…

Outline Course Project Week 5 (100 points) 


It is expected that the outline be submitted in a formal outline format as demonstrated below. Your outline should show enough detail to demonstrate that you have begun thinking about the organization of your paper and the research required into the topic. After your outline, please submit a listing of the sources you have already identified for your paper.


The Introduction part of the paper will provide an executive summary of the issues on fraud and abuse in managed care environments.  It has been proven that fraud and abuse cases cause economic drain on the health care system, including the…

Preventing Fraud and Abuse in Managed Care Final Course Project Week 7 (170 points)


It is expected that the final version of your Course Project will be 7–10 pages in length, with 6–8 sources identified.


Fraud and abuse cases are among the leading reasons why a country’s health care system experiences economic drain.  Despite the vigilance of various sectors in society in ascertaining that fraud and abuse cases in health care are brought to the forefront, only about 10% of these cases…

HSM420 Managed Care Health Insurance

Webliography Week 7 


Over the length of the course, upload three separate URL references to articles relating to current healthcare insurance and managed healthcare issues to the dropbox.


Title: 8 Indicted in Identity Thefts of Patients at Montefiore Medical Center

Web Link: http://www.nytimes.com/2015/06/20/nyregion/8-indicted-in-identity-thefts-of-patients-at-montefioremedical-center.html

Author/Date: Liam Stack, June 19,

Description: A Montefiore employee and seven others were indicted on charges of stealing the personal information of about 12,000 hospital patients and using the…

HSM420 Managed Care Health Insurance

Midterm Exam 


(TCO 1) Describe the preferred provider organization (PPO) model of managed care. Why do you feel that this is the dominant form of managed care today?


In this plan, the patient uses a medical provider under contract with the insurer for an agreed-upon…

(TCO 1) How has the relationship between government and managed care evolved over the years? What factors have driven this changing relationship?


Over the past two decades, managed care organizations (MCOs) have emerged in the United States. The differences between types of managed care organizations are…

(TCO 2) What is the role of the credentialing committee in a managed care organization? And why is this function so crucial?


Credentialing refers to the review of a professional provider’s ability to meet the plan’s standards for participation, being board certified…

(TCO 2) Why do managed care organizations have a board of directors? What is the function of the board of directors?


Managed care has a board of directors to plan and to the shareholders in the event that the plan is for…

(TCO 3) What are the three basic categories of utilization management? Provide a brief description of each category.


The three primary categories of utilization management are: 1.) Prospective is for elective procedures or services prior to such services being…

(TCO 3) What is meant by “outliers” in hospital reimbursement? How do outlier cases impact reimbursement to a hospital?


Outlier’s cases refer to extra payment if a patient’s costs exceed certain thresholds. It is less…

(TCO 4) Discuss some key general aspects of physician practice behavior? Include implicit messages from training, and also environmental factors, in your answer.


As we all know, it takes a long process to be a physician. Thus, physicians are selected for medical school because of certain…

(TCO 4) What is meant by large case management (LCM) under managed care? Provide some specific examples of this type of case management.


Large case management (LCM) under managed care is a process of identifying plan members with special healthcare needs, developing a…

(TCO 7) What is the purpose of the declarations in managed care contracts?


The purpose of the declarations in managed care contracts the parties provide answers to a number of “what if” questions. This is simply…

(TCO 7) What is the purpose of hold-harmless and balance-billing clauses in managed care contracts?


The hold- harmless clause involves the provider agreeing to not pursue a patient for fees in excess of the allowed amount of the…

HSM420 Managed Care Health Insurance

Quiz Week 6 


(TCO 5) What is the purpose of the Privacy Rule? How has this rule impacted healthcare organizations? (Points : 30)

The Privacy Rule went into effect on April 14, 2001, and required that all “covered entities” must…

(TCO 4) What happens if someone alleges that a physician has committed a criminal act such as fee splitting? What organizations would be involved in investigating such an allegation? (Points : 30)

Fee splitting occurs when one physician offers pay another physician for the referral of patients…

(TCO 4) The medical record is legally owned by the  (Points : 5)





(TCO 8) All of the following vaccines and toxoids are required for children by law except (Points : 5)





(TCO 5) The records of all adult patients should be kept a minimum of (Points : 5)

2 years

5 years

10 years

None of the above

(TCO 5) Medicare and Medicaid records should be retained for (Points : 5)

1 year

5 years

10 years

None of the above

HSM420 Managed Care Health Insurance

Discussions Week 1-7 All Students Posts 457 Pages 


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


Indemnity Versus Managed Care – 33 Pages


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


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


Provider Networks – 31 Pages


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?…

Legal Issues in Provider Contracting – 32 Pages


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


Utilization Management – 33 Pages


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


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


Managed Care Pharmacy Benefits – 31 Pages


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?…

Managed Behavioral Healthcare – 27 Pages


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


Managed Care Accreditation – 36 Pages


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?…

HSM420 Managed Care Health Insurance

Managed Care Marketing – 28 Pages


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


Fraud and Abuse – 44 Pages


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?…

Underwriting and Rating – 33 Pages


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


State and Federal Regulation – 34 Pages


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


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…

HSM420 Managed Care Health Insurance