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 | Midterm Exam | Quiz | 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

Course Discussions Week 1-7 All Students Posts 457 Pages 


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?

Yes, you still need to select the plan that is right for you.  While the Affordable Care Act has opened the door for families to obtain insurance there are still differences in the types of plans offered.  If you have a pre-existing condition you would not have to worry about whether or not you would be insurable but you would have to consider what each plan offered.  With a pre-existing condition you don’t want to choose a plan that is the most basic because it may not have the coverage you need to cover your condition or treatments.

It is very important to educate yourself on what each plan offers because they are all different.  Certain testing or procedures may not be covered in one tier but may be covered in another tier.  You also need to take into consideration the cost of the plan.  Within the Market Place the policies vary in price.  One policy may have a lower out of pocket cost but has higher premiums and another is the opposite having a higher out of pocket cost and lower premiums.  We must always be aware of what we are purchasing when choosing a health plan even with the Affordable Care Act in place to ensure we select the plan that is the best fit…

HSM420 Managed Care Health Insurance

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?

This has definitely affected many people. Another thing I would like to add is high prescription costs. My father-in-law has Medicare insurance and another supplemental insurance, but some of the prescriptions are NOT covered by his managed care plans, or are extremely expensive. He still works to earn an income to be able to support these types of expenses. I sometimes feel like when you retire, you never really retire because there will always be expenses that come up and you can’t live off of social security payments and earned savings…

HSM420 Managed Care Health Insurance

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?

Although it may be possible for a MCO to survive without a provider network, it is extremely difficult. Because there are many benefits to the MCO that come from establishing provider networks, MCOs without networks end up working much harder to remain viable. “Managed health care plans such as PPOs and HMOs are dependent on their networks to deliver medical care to their subscribers; even closed-panel HMOs depend to some degree on a network of private physicians and hospitals.”

If the MCO does not have an established network, there is no guarantee that their member will be treated by any providers. Not only can access to care be limited for members in MCOs without networks, when they do find a provider to treat them it could come at a must higher cost. One of the benefits of provider networks is that prices are reduced, and the payer never pays full price for services. If there is a higher cost to the payer, there will be a higher cost to the members. Members will probably not be happy to pay higher prices and premiums, so they will likely seek out a new insurance company. Eventually, this will result it losses for the MCO, and as stated earlier, it will be extremely difficult to remain viable. With higher costs, no guarantee of access to care for members, potential loss of members, and lower profits, it does not make sense for a MCO to choose not to have an established provider network. Although possible, it is not really probable because of all of the extra problems that come along with being without a network…

HSM420 Managed Care Health Insurance

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?

Under a competitive bidding system, hospitals might submit bids in advance indicating the payment they would accept for each type of episode. CMS could then exclude high bidders from Medicare or use an average of the bids to set its payment rate. In theory, bidding systems can quickly reveal the costs that efficient providers incur. In practice, however, providers that are not already integrated to deliver the full spectrum of patients’ care during an episode might have trouble determining an appropriate bid. As experience with bundled payments grew, those challenges could become more manageable; thus, one option might be for the payment-setting mechanism to evolve over time from administered pricing to competitive bidding. Even then, however, many hospitals and some medical specialists might not have strong incentives to bid their true costs, partly because of limited competition in their markets.

Method of Payment. The concept behind bundling payments is generally to make a fixed payment per bundle, so that providers collectively bear all of the excess costs if total spending exceeds the fixed payment and get to keep all of the savings if their costs are lower than that payment. One way to implement that approach would be to make a single, prospective payment to one individual or organization—such as the hospital responsible for the initial admission—and require that recipient to arrange payments to other providers delivering the care covered by the bundle. For bundles that applied only to services provided during a hospital stay (including physicians’ services), that approach would seem relatively easy to administer; it is the payment method that CMS adopted for Model 4 of its current demonstration. For bundles that included services provided after discharge from a hospital, however, a single prospective payment to the hospital could prove complex to administer: The hospital would need to have payment arrangements with—and oversee—all of the various providers that might be involved in delivering care after a patient was discharged…

HSM420 Managed Care Health Insurance

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?

According to the Institute of Medicine Committee, utilization management is a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision.

In my research of utilization management, the terms management & review were used interchangeably.  So, I am a little confused about the term since management & review have different meanings.  According to our text, the categories used in utilization management were prospective, concurrent, retrospective, pended (for review), denial (no authorization), and sub authorization…

HSM420 Managed Care Health Insurance

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?

Case management targets high-risk patients–those who, because of diverse combinations of health, social and functional problems, are likely to need hospitalization. The cost for this type of patient is high and the goal is to coordinate cares to improve continuity and quality of care as well as lower the cost of treatment.  Case management is a collaborative process that assesses plans, implements, coordinates, monitors and evaluates the options to meet the needs of the patient.

Disease management targets patients who have one major diagnosis and who, because of their major diagnosis, have a relatively standard set of needs. It encompasses all settings of care and places emphasis on prevention and maintenance.  It is more focused on the set of diseases…

HSM420 Managed Care Health Insurance

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?

As a patient I want to be able to get my prescribed medications filled at a cost that I can afford.  I want to be able to fill the medications my provided decides I need and the pharmacy benefits of my plan to cover that medication.  It is really frustrating when you are prescribed a medication and your plan doesn’t cover it therefore if you want to take the medication to help you recover you must pay out of pocket for it.  It can get really expensive.  Another frustrating area is when a patient is prescribed a medication and can’t even begin to cover the copay for that medication.

There is a chemo medication that some cancer patients are prescribed and the copay with Medicare is $60,000 per month.  How can a patient afford that copay?  It is ridiculous. These patients need this medication to survive and many are unable to afford it.  I have a patient that I have been working with to get the copay cover by the manufacturer and it is very difficult.  The patient has to be given the chemo then the organization has to submit a claim to Medicare wait for the denial, appeal that denial, and then appeal to the manufacturer.  It is a long difficult process.  It would be easier to get this patient assistance through the manufacturer if she did not have a government based insurance plan or if she had no insurance at all.  Manufacturers don’t usually help with drug costs if a patient is on Medicare or Medicaid.  This is very frustrating for both the patient and the providers.  So I would like to see medications that a patient needs covered in an affordable manner by the pharmacy plans…

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?

One issue that I have seen is that most of these patients have to be held in an emergency department for a certain number of hours prior to being admitted for treatment.  This can cause safety concerns for other patients and staff because the emergency department is not equipped to treat these patients or hold them in a safe manner.  In my organization this puts a major strain on our resources.  It takes extra staff to provide the necessary attention to help these patients until they are admitted.  Some of these patients are dangerous and emergency rooms are set up to handle emergency medical treatment not behavioral health patients.  By being held in and emergency department these patients experience delayed treatment.  Yes the are treated by physicians and nurses but not all organizations have behavioral health professionals with in the emergency department.  If a cardiac patient were to come into an emergency department their treatment is not delayed but a behavior health patients is.  I understand that certain patients don’t need as much urgency as others to save their lives but there is still an urgency to treat them.  They need assistance just like the cardiac patient does – just a different form…

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?

In order for a health care organization to participate in and receive payment from the Medicare or Medicaid programs, it must meet the eligibility requirements for program participation, including a certification of compliance with the Conditions of Participation (CoPs) or Conditions for Coverage (CfCs), which are set forth in federal regulations. The certification is based on a survey conducted by a state agency on behalf of the federal government, the Centers for Medicare & Medicaid Services (CMS) or a national accrediting organization, such as The Joint Commission, that has been approved by CMS as having standards and a survey process that meets or exceeds Medicare’s requirements. Health care organizations that achieve accreditation through a Joint Commission deemed status survey are determined to meet or exceed Medicare and Medicaid requirements…

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?

Heath care marketing do vary based on location, for example, my mom has Medicaid and when we moved to long island from queens, NY. We had to first transfer her file from queens county to Suffolk county which took three to four months and now we are waiting for Suffolk county office to send us her new health plan where as in queens, you have to go around shop for one using NY State health care market website. so meanwhile, she cannot go see doctor until we receive new health plan…

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?

HIPAA has many similar steps for protecting patient information as do laws to protect customer personal information in banking. Unfortunately, I have seen many people use stolen or fake identification to open accounts or transact some other business. Sometimes a son will use the father’s identification or an ex will gather information just because they know the proper answer to security questions. I can understand this being done at a doctor’s office. My husband, who used to be a pharmacy tech, would tell me stories of people with fake or stolen identification trying to get fake prescriptions filled…

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?

Whenever I see underwriting I think of those that work in that area what a job they have. Think about it with all that they have to evaluate which is done every single year all that information that is gathered from so many facilities and practices I am sure is overwhelming.  I have been in offices where we had to give that information gathered both by hand and then later by electronic gathering to the underwriters such as how much new patient charges and charges for certain problems etc. This has to be a major daily headache for those that are doing this job. I also have been in office starting of the new changes for charges and procedures when those notes come down the pike I am like okay we need to change this or that then I think if it has fallen why is it the economy that is making this or are physicians getting away with overcharging and got caught now everyone has to lower their charges. I think like that because it is things like that which can make a major change.

I am sure there are hundreds of reasons and unless you are an underwriter and know exactly why we at this end just get the news and make changes if any accordingly.  I for one am so glad we have them keeps things on track if we did not have this we would all feel the effects…

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?

States have enacted a broad range of laws affecting managed health care, including requirements for the cooperate structures of payers, types of products sold in the individual and group insurance markets, information disclosures and other consumer protections, coverage mandates, contracting with health care providers, and solvency standards.
In consumer protections alone, there are several areas in which our states require full disclosures, fair billing practices, notice to privacy protections, appeals information, UR, and market review.

Have you ever read every page of the insurance packet you receive at a new job? Or the information we receive from our providers practices letting us know how they protect our privacy? Imagine not knowing all you know now; imagine if you didn’t have all that information at your fingertips. To actually read this stuff definitely makes us want to take a nap, but I’m glad there are people with our smarts and even smarter out there with the power to enforce these rules and regulations for our protection…

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 are 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.

Supposedly, the Affordable Care Act was created to ensure that all Americans have access to quality and affordable healthcare.  Some agree that it is working for them and others, not so well.  My sister found insurance through the health exchange that by the way, I had never heard of.  She had to take my nephew to the emergency room on Thanksgiving and the hospital refused her insurance.  We tried making other appointments for him to no avail.  I don’t know how reputable the companies are that advertise there.  I would hope that before they can be accepted by the exchange that they have been checked out to be reputable…

HSM420 Managed Care Health Insurance