HSM546 Course Discussions Week 1-7


HSM546 Course Discussions Week 1-7
In your own words, define managed care and discuss how managed care impacts healthcare delivery…

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HSM546 Course Discussions Week 1-7

HSM546 Course Discussions Week 1-7

All Students Posts – 624 Pages

Week 1 All Students Posts 92 Pages 


Managed Care and Current Trends – 45 Pages 


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?…

HSM546 Course Discussions Week 1-7

Quality and Access – 43 Pages 


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?…

Week 2 All Students Posts 92 Pages 


Health Maintenance Organizations – 42 Pages 


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?

Governance of Managed Care Organizations – 39 Pages 


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?…

Week 3 All Students Posts 92 Pages 


Provider Networks – 44 Pages 


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?…

HSM546 Course Discussions Week 1-7

Federal Regulations – 47 Pages 


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?…

Week 4 All Students Posts 92 Pages 


Provider Payment – 41 Pages 


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?…

Claims and Benefits – 47 Pages


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?…

Week 5 All Students Posts 92 Pages 


Legal Issues – 43 Pages


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…

Fraud and Abuse – 48 Pages 


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?

Week 6 All Students Posts 92 Pages 


Utilization Review – 47 Pages 


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?…

Medicare Advantage Plans and Medicaid Plans – 45 Pages 


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?…

Week 7 All Students Posts 92 Pages 


State Regulations of Managed Care Plans – 47 Pages 


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?…

Federal Regulations of Managed Care Plans – 45 Pages


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?…

HSM546 Course Discussions Week 1-7