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Managed Care Course
Problems and Pain Points that I will solve:
- Anxiety
- Tired of trading time for money
- Stagnant career growth/unclear path
- Uncertainty of where medicine is going
- What adjustments do you need to make to survive. What adjustments to your sails have to be made to accommodate the changing winds and the upcoming storms?
- Burnout
- Decreased self-esteem from the power given to nonphysicians that manage you
- Helpless to impact the momentum of change in the landscape
- Decreased professional respect
- Financial insecurity
- Increased demands not reconciled with increase compensation
- Subjects and skills not taught in medical school are needed now and hamper your ability to make the best decisions now and in the future
- Usually ignored by administrators, sometimes patients and colleagues
End Results:
- A comprehensive understanding the environment and ground rules to make better and more informed decisions for the future
- Obtain tools and a skill set to be more successful and increase revenue
- Achieving a worklife balance that will allow you to be proud of the legacy that you will be for your family friends and the patients that you serve
- Increase career options
- Ability to adjust your sails to the winds and storm accordingly to effectively navigate the many changes in healthcare presently
- Financial legacy
- Reposition yourself for leadership roles and salary increases
- Improve the quantity and quality of professional relationships because you bring more to the table
- You will gain confidence, clarity, and authority
- You will make a high-level impact on healthcare delivery systems
Course Outline
Module I. Introduction
- L-1 A. Why this is important
- # of MCOs in US.
% of citizens covered by an MCO - GNP and $$ per person spent on health care in US
- Medicaid and Medicare history
- # of MCOs in US.
- L-2 B. Impact on practices and livelihood
- L-3 C. Core competences needed
- Contracting
- Finance
- Utilization management
- Quality management
- Population health management
- Information Systems
- Health Policy
- Health Law
Module II: History of Managed Care and Health Insurance Coverage
- L-1 A. History
- L-2 B. Structure, organization
- L-3 C. Health laws, regulation and oversight
- L-4 D. Role of non-governmental organizations
- L-5 E. Conflicts and the role of the court
Module III Core Depts. – Clinical, Operations, Finance, Compliance, IT, Data Analytics(Economics), Standard Data Sets
- L-1 A. Operations
Provider Network (Includes Hospital and Ancillary Facilities)- Contracts and contracting
- Service access, access standards, network adequacy
- Network maintenance
- L-2 B. Clinical, Operations, Finance, Data, IT (standard code sets) Compliance
- Provider Payments
- a.Risk based vs non risk based
- b.Value based
- c. Cost sharing
- Provider Incentives
- Member/Pt Incentives
- Prescription payment/Formularies
- Combined payment of physicians and hospitals
- Payment of ancillary Services
- Provider Payments
Module IV Utilization Management and Accreditation
- L-1 A. Measuring utilization management
- Medical necessity, benefits and coverage determinations
- Basic utilization management.
- UM of ancillary facilities
- Management of Pharmacy benefits
- Appeals
- L-2 B. Prevention and Wellness
- C. Disease Management, Case Management, Transition Care
Management, Pt. Centered Medical Homes - D. Behavioral Health Integration
- L-3 F. Program Evaluation
Public and Population Health Principals
Module V Quality Management
- L-1 A. Accreditation – HEDIS/NCQA
- L-2 B. Certification
- L-3 C. Recognition Programs
Module VI Fundamentals of marketing, governance (Rules of the Governing Bodies) and Administration
- L-1 A. IT
- L-2 B. Administrative simplification
- L-3 C. Analytics and informatics
- L-4 D. Marketing and sales of commercial products and services
- L-5 E. Acturial Services, underwriting, and premium rate setting
- L-6 F. Eligibility
- L-7 G. Enrollment and Billing
- L-8 H. Claims and benefit administration
- L-9 I. Fraud, waste, and abuse
- L-10 J. Member Services
- L-11 K. financial management
- L-12 L. Operational challenges in payer industry
Module VII - Medicare and Medicaid
- L-1 Medicare
- L-2 Medicaid
Module VIII- Health Equity
- L-1 Importance/ Requirement to be foundational for best results
- L-2 Establish Foundation
- A. Collection of REALL data
- L-3 Medical records from all points of svc
- L-4 Capturing data from people who don’t interact with the health care system
- L-5 Attention to Social Determinants
- L-6 Collaborating with CBOs
- L-7 Measuring progress
Module IX- Leadership, Decision Making
- L-1 Leadership development
- L-2 Advocacy
Module X – The Future
- L-1 Opportunities
- L-2 Challenges
- L-3 Preparing for the unique role that you can play in the future of healthcare
Schedule Of Lessons
Day 1
| Module No. | Min | Lessons |
|---|---|---|
| 1 | 45 |
Introduction 1. Why is this topic important 2. Impact on practices and livlihoods 3. Core competencies needed |
| 2 | 45 |
History of Mgd. Care 1. History 2. Structure and organization 3. Health laws, regulation, and oversight 4. Role of non-governmental organizations 5. Conflicts and the role of the courts |
| 3 | 135 |
Core Depts 1. Operations 2. Clinical Operations, Finance, Data, IT, Compliance |
| 4 | 90 |
Utilization Management and Accred. 1. Measuring UM 2. Prevention and Wellness 3. Disease Mgmt, Case Mgmt, 4. Transition Care Mgmt, Pt. Ctrd, 5. Medical Homes, BH Integration 6. Program Evaluation |
| 5 | 45 |
Quality Management 1.Accreditation 2. Certification 3. Recognition Programs |
Day 2
| Module No. | Min | Lessons |
|---|---|---|
| 6 | 135 |
Fundamentals of marketing governance and Governance 1. IT 2. Adm. Simplification 3. Analytics and informatics 4. Marketing and sales of commercial products 5. Actuarial Services 6. Eligibility 7. Enrollment and Billing 8. Claims and benefit administration 9. Fraud, waste, and abuse 10. Member services 11. Financial management 12. Operational challenges in payer industry |
| 27 | 45 |
Medicare and Medicaid 1. Medicare 2. Medicaid |
| 8 | 90 |
Health Equity 1. Importance 2. Establishment of foundation 3. Medical records from all points of service 4. Capturing data from people who don’t interact with the health care system 5. Attention to Social Determinants 6. Health Literacy 7. Collaborating with CBOs 8. Measuring progress |
| 9 | 45 |
Leadership, Decision Making 1. Leadership development 2. Advocacy |
| 10 | 45 |
The Future 1. Opportunities 2. Challenges 3. Preparing for the unique role that you can play in the future of healthcare |
