Mastering Managed Care and Health Insurance
(14.4 Contact Hours)
Written by Barbara Katz, RN, MSN
The price of this course is $59.00. You will only be asked to pay for the course if you decide to grade the Post Examination to earn a certificate with Contact Hours (CEUs).
Course Instructions and Learning Objectives
Since the early 1980s managed care has become the dominant form of health insurance in the U.S. Because managed care is so closely intertwined with health care delivery a basic understanding of managed care health insurance concepts is essential for anyone who delivers, finances administers or sells health care services. After completing this course participants will be better able to perform health insurance related jobs, communicate more effectively with managed care plan personnel, help patients resolve managed care insurance problems and improve reimbursement from managed care plans.
After completion of Mastering Managed Care and Health Insurance you will be able to:
1) Define managed care health insurance terminology
2) Understand managed care documents, forms and publications
3) Describe the most common types of managed care products and programs
4) Explain roles and responsibilities in managed care health insurance
5) Identify managed care health insurance issues that impact clinical practice
6) Identify and resolve common managed care health insurance problems
Course Structure
Each section of the program describes one component of managed care health insurance. The body of the chapter describes key terms and concepts and gives examples. The Check Point multiple choice or matching questions are designed to help you test your understanding of the content in the chapter. Some chapters include a case study entitled In Real Life. These case studies provide practical examples of the concepts contained in the section. The section entitled Think About It is an exercise that is designed to help you apply what you have learned in the chapter. In many cases there is no one right answer to this exercise. The Glossary, which is at the end of the program, provides an alphabetic listing of managed care and health insurance terms contained in the program.
Course Outline
Module 1- What Makes Health Insurance Tick?
A basic introduction to health insurance terms and concepts.
Module 2 - The Managed Care Maze
Definition of managed care Characteristics of managed care plans Types of managed care plans and programs
Module 3 - What’s Covered – Benefits and Exclusions
Types of health insurance benefits in managed care Benefit limits and requirements Exclusions Riders and pre-existing conditions
Module 4 - Managed Care Arithmetic
Managed care payment terms and definitions Provider payment arrangements Cost sharing mechanisms in managed care
Module 5 - Network Ins and Outs
Network definitions Credentialing Network and provider terms and definitions Physician education and credentials Provider directories
Module 6 - Utilization Management
Utilization management definitions Utilization management techniques Organizing plan referral rules
Module 7 - Quality Issues in Managed Care
Accreditation of managed care plans Performance measurement tools Clinical quality improvement techniques Appeals and managed care patient safeguards The Health Insurance Portability Act privacy provisions
Module 8 - Medicare
Medicare eligibility Medicare components Primary vs. secondary Medicare coverage Medicare definitions and terms
Module 9 - Medicaid and Other Government Health Insurance Programs
Medicaid definition Program components and eligibility State programs Federally mandated benefits Managed Medicaid Other Government Health Insurance Programs
Module 10 - Insurance Information Exchange (Enrollment, Membership and Registration)
Enrollment and membership definitions Steps in the insurance information exchange The member identification card Plan documents
Module 11 - The Medical Encounter
Medical encounter flow Coding Documentation
Module 12 - Claims and Billing
Claims and Billing Flow Claims definitions Claims examination and payment Explanation of benefits and remittances Medical billing statement example
Module 13 - Resolving Insurance Problems
Steps in problem solving Insurance processing checklist Table - Problems and Who Can Help to Solve Them Levels of problem solving
Health Insurance and Managed Care Resources
Glossary of Managed Care Health Insurance Terms
