AHM 250: Course Objectives Healthcare Management: An Introduction

This course provides a comprehensive overview of the health plan industry, including operational, financial and ethical issues. You will learn:

Assignment 1: The Evolution of Healthcare Delivery and Financing in the United States

Reading 1A: The Evolution of Healthcare Delivery and Financing in the United States

• Define managed care • Identify the major factors that influenced the evolution of healthcare delivery and financing in the United

States • Describe the role of the government in the development of healthcare delivery and financing • List and describe some factors that limit accessibility to healthcare • Discuss how the meaning of quality (as it relates to healthcare) has changed

Reading 1B: Basic Concepts of Benefits, Coverage, and Insurance

• Explain how traditional indemnity health insurance works • List some characteristics of the fee-for-service payment system • Define antiselection • Explain how deductibles and coinsurance are used in traditional indemnity plans • Describe some efforts commonly used to combat the rising costs of healthcare

Assignment 2: Basic Concepts of Health Plan Industry

Reading 2A: Managed Care - Benefits and Networks

• Define primary care and describe its role in a health plan • Define copayment • Define network and explain its importance in a health plan • Describe how health plans influence and affect availability of healthcare

Reading 2B: Financing Health Plans

• Discuss how managed care plans combine the financing and delivery aspects of healthcare • Define capitation • Explain how capitation differs from fee-for-service compensation • Identify and describe various financing arrangements between health plans and physicians and hospitals

Assignment 3: Health Plans, and Products

Reading 3A: The Health Maintenance Organization (HMO)

• Identify and describe the general characteristics of HMOs

Reading 3B: Types of HMO Models

• Differentiate between a closed-panel HMO and an open-panel HMO • Distinguish among the various HMO models in terms of provider relationships and compensation

arrangements

Reading 3C: PPOs, POSs, and Managed Indemnity

• Describe a preferred provider organization and explain how it differs from other types of health plans • List and describe two characteristics common to most POS products • Describe one major difference between an EPO and a PPO

Assignment 4: Health Plans for Specialty Services

Reading 4A: Health Plans for Specialty Services

• Explain how a health plan might carve out the delivery of specialty services • Define specialty HMOs • Describe three types of managed dental plan • Describe the four basic strategies that managed behavioral health organizations (MBHOs) use to manage the

delivery of behavioral healthcare services • List four activities that a typical pharmacy benefit management (PBM) plan uses to manage pharmaceutical

utilization

Assignment 5: Provider Organizations

Reading 5A: Provider Organizations

• Explain what it means for providers to integrate • Describe some of the advantages of provider integration • Discuss some of the types and levels of provider integration • Describe the general characteristics of several types of provider organizations

Assignment 6: Health Systems Management

Reading 6A: Health Plan Structure and Management

• Describe the most important functions of a health plans board of directors • Identify a health plan's key management positions and their functions • Identify the common medical management committees and describe the committees' general functions

Reading 6B: Network Structure and Management

• Describe some of the factors commonly evaluated in a market analysis for network management • List the types of providers typically included in a health plan's network • List and explain some of the factors that influence the number of providers included in a health plan's

network • Define credentialing and explain why it is important • List some common clauses and provisions in provider contracts

Assignment 7: Medical Management I

Reading 7A: Basics of Utilization Management

• Define medical management and identify its component parts • Describe the strategies health plans can use to manage member demand for healthcare services • Identify the kinds of cases for which case management is typically used • Define disease management

Reading 7B: Utilization Review and Authorization Systems

• Explain the purpose of utilization review • Define authorization and explain the criteria health palns use to determine whether benefits are payable • Describe the types of services that require utilization review and authorization • Identify the three types of utilization review • Describe the utilization review process • Discuss some of the techniques health plans use to manage utilization review and authorization processes

Assignment 8: Medical Management II

Reading 8A: Quality Assessment and Improvement

• Identify the two types of quality delivered by health plans • Describe the methods health plans use to assess the quality of administrative and healthcare services • Describe the advantages and disadvantages of using structure measures, process measures, and outcomes

measures to evaluate healthcare quality • Discuss three tools health plans commonly use to improve performance and quality

Reading 8B: Quality Standards, Accreditation, and Performance Measures

• Identify the major agencies that provide accreditation for healthcare organizations • Explain the role of quality standards in the accreditation process • Describe the most important sources and types of performance measures

Assignment 9: Managed Healthcare Operations I

Reading 9A: Healthcare Marketing for Health Plans

• List the elements of the marketing mix and describe their role in the marketing process • List several forms of marketing research that health plans use to obtain information about their customers • Explain the major objectives of benefit design • Describe the market segments that comprise the non-group market • Explain the impact of state regulations on marketing to the Medicaid population • Explain the differences between small groups and large groups that affect marketing efforts directed to each

of those segments • Explain which promotion tools and forms of distribution are used most frequently in the non-group and group

markets

Reading 9B: Underwriting, Rating, and Financing

• Define underwriting and explain the differences between new business underwriting and renewal underwriting

• Identify and describe the characteristics of typical rating methods used by health plans in setting premiums • Identify and define key accounting and financial reporting terms for health plans • Explain the differences between fully funded and self-funded health plans

Assignment 10: Health Plan Operations II

Reading 10A: Information Management

• Describe the kinds of information and information systems capabilities needed by health plans • Discuss some of the primary challenges for managing data and information • Discuss the use of the following information technologies in the health plan industry: • Electronic commerce • Electronic data interchange • Decision support systems • Data warehouses • Electronic medical records • Health information networks

Reading 10B: Claims Administration for Health Plans

• Define encounter • Describe some of the key positions in a claims administration department • Explain the steps followed to process a health plan claim • Describe some types of information an automated claims database needs to contain

Reading 10C: Member Services

• Describe four types of member services activities commonly conducted by health plans • Describe several ways in which health plans use technology to facilitate the delivery of member services • Explain how health plan arrangements for providing member services vary from company to company • Describe the considerations for managing accessibility, people, processes, technology, and performance for

member services

Assignment 11: Legislative and Regulatory Issues in Health Plans

Reading 11A: Federal Laws and Regulations

• Identify and describe federal laws and regulations that apply to health plans • Explain the role that federal laws and regulations play in protecting consumers and maintaining a level

playing field in the marketplace

Reading 11B: State Laws and Regulations

• Compare the key components of state regulations for HMOs and other health plans • Describe the major functions that health plans perform that are subject to state regulation

Reading 11C: Government-Sponsored Programs

• Describe the role of the federal government as purchaser of managed healthcare benefits for the elderly (Medicare), those with low income (Medicaid), federal employees and dependents (Federal Employee Health Benefits Program [FEHBP]), and inactive and retired military personnel (TRICARE)

• Discuss the application of managed care principles to workers' compensation

Assignment 12: Ethical Issues in Health Plans

Reading 12A: Introduction to Ethics in Health Plans

• Define ethics and explain the difference between ethics and laws • Describe some ways that health plans can foster an ethical corporate culture

AHM 510: Course Objectives Governance & Regulation

This course describes the formation, types, and structure of health plans. It addresses the role of health plans in government-sponsored pro-grams, the impact of fraud and abuse, how the purpose of an individual health plan is determined, and the role of public policy in the health plan industry. You will learn:

Assignment 1: Environmental Forces

Reading 1A: Environmental Forces

• Name and describe several major factors shaping the environment of health plans • Describe the players in health plans and how their interests affect the way they influence the healthcare

environment • Explain the influences accreditation organizations and the media exert over the financing and delivery of

healthcare • Describe several possible governance responses that health plans make to deal with their changing

environment

Assignment 2: Legal Organization of Health Plans

Reading 2A: Legal Organization of Health Plans

• Explain the distinguishing features of a corporation and a limited liability company • Describe the key features and differences between a for-profit company and a not-for-profit company • Describe the differences between a publicly traded stock company and a privately held stock company • Describe the key features and differences between a stock company and a mutual company

Assignment 3: Formation and Structure of Health Plans

Reading 3A: Corporate Restructuring and Corporate Transactions

• Describe the options available to mutual companies seeking access to capital, strategic partnerships, and other corporate transactions

• Describe the issues that a not-for-profit entity must address when converting to for-profit status or when engaging in other transactions with for-profit entities

• Explain how health plans use reorganization and reengineering to improve performance • Distinguish between strategic partnerships, joint ventures, acquisitions, and mergers

Reading 3B: Health Plan Care Structures and Arrangements

• Identify and describe the various types of sponsors of health plans • Discuss the objectives of providers in health plan structures and arrangements • Discuss the impact of changes in health plan structures and arrangements on regulation • Differentiate between horizontal, vertical, and conglomerate integration • Differentiate between structural, virtual, and operational integration

• Explain how strategic, marketplace, and regulatory issues can shape health plan structures and arrangements • Describe various arrangements employers use to provide healthcare benefit plans for their employees

Assignment 4: Overview of Laws and Regulations

Reading 4A: Perspective and Overview of State and Federal Laws

• Describe the sources of law in the United States • Explain the significance of the HMO Act of 1973 in the development of managed care • Name the federal laws that stimulated health plan participation in Medicare and Medicaid • Describe the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) of

major interest to health plans • Describe the aspects of a health plan on which state regulations usually focus

Reading 4B: Regulatory Agencies and Health Plans

• Explain the role of CMS in regulating healthcare • Describe the role of the Department of Labor in regulating health plans • Explain the methods states use to delegate regulatory authority for health plans to state agencies

Assignment 5: State Regulation of Health Plans: Part I

Reading 5A: State HMO and Other Types of Health Plan Laws

• Describe the major provisions of the NAIC HMO Model Act • Describe the types of state regulation that apply to PPO, URO, TPA, PSO, and POS products • Explain the need for the Risk-Based Capital for Health Organizations Model Act and the risk-based capital

formula

Reading 5B: State Mandates and Regulation of the MCO-Provider Relationship

• Describe the difference between a mandated benefit and a mandated provider law • Give examples and explain the purpose of several mandated benefit laws • Describe the problems with applying any willing provider laws to certain types of health plans • Explain why state mandates often increase the cost of healthcare services provided by health plans

Assignment 6: State Regulation of Health Plans: Part II

Reading 6A: Other Laws That Apply to Health Plans

• Describe the various types of state laws, other than HMO and insurance laws, that apply to health plan products

• Explain how states regulate agent licensing, marketing activities, and advertising • Describe common types of general insurance laws that apply to health plans

Reading 6B: Workers' Compensation Programs

• Describe the kinds of benefits injured employees receive under workers' compensation • List several ways in which workers' compensation differs from other types of healthcare coverage • Describe how state laws can limit the use of managed care to provide workers' compensation benefits • Describe some of the common features of workers' compensation managed care plans • Describe the features of an integrated health and disability plan

Reading 6C: Pharmacy Laws and Legal Issues

• Describe the various types of open pharmacy laws • Describe how states regulate mail-order/ mail service pharmacy programs • Describe how states regulate use of formularies and generic substitution • Explain the benefit exclusions for an experimental drug, an investigational drug, and the off-label use of a

drug • Describe how the Nonprofit Institutions Act applies to prescription drug pricing • Describe how states regulate an health plan's use of drug utilization review programs

Reading 6D: Market Conduct Examinations and Mechanisms for Enforcement

• List the operations that a state insurance department reviews in conducting a market conduct examination • Describe the enforcement mechanisms available to states to address violations of law

Assignment 7: Federal Regulation of Health Plans

Reading 7A: Federal Regulation of Health Plans

• Describe some of the operational and quality requirements that federally qualified HMOs must meet • Explain some of the administrative burdens that the Health Insurance Portability and Accountability Act of

1996 (HIPAA) imposes on health plans • Describe the general provisions of the Mental Health Parity Act of 1996 and the Newborns' and Mothers'

Health Protection Act of 1996 • Explain several typical applications to health plans of the Americans with Disabilities Act

Reading 7B: Antitrust Concerns and Health Plans

• Describe the three major federal laws that regulate business activities to prevent antitrust actions • Describe the difference between the per se rule and the rule of reason • Explain the applications of antitrust law in health plan-provider contracting • Explain the relevance of antitrust in mergers and acquisitions • Identify the issues that the 1994 DOJ and FTC guidelines addressed • Explain the procedures the DOJ and FTC follow for their enforcement proceedings

Reading 7C: ERISA and Health Plans

• Describe ERISA's documentation, reporting, and disclosure requirements • Describe the minimum standards of conduct (the fiduciary duties) applicable to ERISA plan fiduciaries • Describe the claims procedures required under ERISA and the standards of review that courts apply in

deciding disputed claims • Describe how ERISA preemption has been applied by the courts to: utilization review and credentialing

decisions made by health plans; mistaken verification of eligibility by an employer or health plan to a healthcare provider; entities that perform administrative functions under an ASO contract; and provider networks that contract to provide healthcare services to either health plans or self-funded employers on a capitated basis

Assignment 8: Federal Government as Purchaser

Reading 8A: Federal Government as Purchaser: Overview, TRICARE, and FEHBP

• Explain the government's dual role as purchaser and regulator of healthcare services • Describe the evolution of the military health services system from CHAMPUS to TRICARE, and describe

TRICARE's triple benefit structure

• List the primary features of the Federal Employees Health Benefits Program (FEHBP) • Describe how actions taken by the Office of Personnel Management (OPM) have a positive influence on

FEHBP

Reading 8B: Medicare and Heath Plans

• Describe the types of Medicare health plan contracts • Explain the certification process for a Medicare PSO • List the three ways that payment rates will be determined for health plans under Medicare + Choice • Explain how a Medicare Medical Savings Account works • Describe health plan contracting standards under the Medicare + Choice program • Provide examples of Medicare marketing restrictions

Reading 8C: Joint Federal-State Healthcare Programs

• Explain the roles of the federal and state governments in the operation of the Medicaid program • Describe the Medicaid services mandated by the federal government • Describe effects of the Balanced Budget Act 1997on regulation and operation of Medicaid managed care

programs • Name the types of managed care entities that can contract to provide Medicaid services • Explain the purpose of Section 1915(b) and Section 1115 waivers • Explain how states can mandate Medicaid managed care without obtaining a waiver • Explain the role of Programs of All-Inclusive Care for the Elderly (PACE) • Discuss the purpose and options for implementation of the State Children's Health Insurance Program

(SCHIP)

Assignment 9: Fraud and Abuse

Reading 9A: Fraud and Abuse

• Define the terms fraud and abuse • Describe how different types of compensation arrangements can lead to different kinds of fraud and abuse • List and describe the federal laws that regulate healthcare fraud and abuse, and identify the federal agency

responsible for enforcing them • Describe the penalties that may be imposed for violating the federal fraud and abuse laws • Discuss some of the steps health plans can take to reduce fraud and abuse

Assignment 10: Governance: Structure and Strategy

Reading 10A: The Components of Governance in a Health Plan

• Explain the purpose of governance in a health plan • Describe the roles and responsibilities of the board of directors • Explain how organizational variations affect board structure and operation • List the three steps in a board risk management program • Describe the roles of shareholders/members and providers in governance • Discuss the roles and responsibilities of the CEO and other senior management

Reading 10B: Strategic Planning in Health Plans

• Define strategic planning • Explain why strategic planning is important to a health plan • Describe the four primary activities in strategic planning

• Explain the importance of input and ownership in strategic planning

Reading 10C: Key Strategic Issues for Health Plans

• Identify and describe the key strategic issues faced by health plans • Give examples of how key strategic issues are interrelated in the strategic planning process

Assignment 11: Governance: Accountability and Leadership

Reading 11A: Governance: Accountability and Leadership

• Discuss accountability among the stakeholders in managed care • Explain several implications of accountability on health plan leadership and governance • Describe the essential elements of an effective health plan compliance programs • Define medical necessity and describe how health plans address related governance issues • Describe quality and ethics programs and ombudsman programs

Assignment 12: Key Legal Issues in Managed Care

Reading 12A: Key Legal Issues in Managed Care

• Define breach of contract, negligence, medical malpractice, and punitive damages • Discuss the obligations that health plans owe to plan members in conducting utilization management

activities • Describe the standard of care health plans must meet when they credential plan providers • Discuss two theories of liability that may make health plans liable for the medical malpractice of plan

providers • Describe how ERISA affects the ability of plan members to bring legal actions against health plans • Identify and describe some legal issues that may arise between health plans and plan providers • Discuss some of the federal and state laws that regulate the business conduct of health plans

Assignment 13: Public Policy and Changing Environment

Reading 13A: Public Policy from the Health Plan Perspective

• Explain some of the ways that health plans influence public policy • Identify primary interest groups in each of the major healthcare sectors that participate in efforts to affect

health plan public policy • Describe several types of advocacy and political activities undertaken by interest groups in the health plan

policy debate • Discuss the role of litigation in determining health plan public policy • Describe several techniques interest groups use to affect public opinion

Reading 13B: Changing Environment and Emerging Trends in the Health Plan Industry

• Identify several key environmental factors that affect health plans • Describe the underlying tension between universal healthcare coverage and comprehensive healthcare

benefits • Explain how marketplace reform and regulatory reform have brought about change in the health plan industry

AHM 520: Course Objectives Health Plan Finance & Risk Management

This course provides a comprehensive examination of health plan finance. After exploring financial management techniques, the course addresses plan funding, risk management, provider reimbursement, and plan risk. Pricing, underwriting and rating methods also are covered in detail. You will learn:

Assignment 1: Health Plan Financial Information

Reading 1A: Health Plan Financial Information

• Define financial information and list examples of a health plan's financial information • Identify the internal users and external users of a health plan's financial information • Distinguish between for-profit and not-for-profit health plans • Discuss the common types of health plan products

Assignment 2: Risk Management in Health Plans

Reading 2A: Types of Risk

• Distinguish between pure risk and speculative risk • Define risk management • Define the risks included in risk-based capital (RBC) requirements for health plans • Discuss the three broad strategies health plans use to deal with risk • Explain how C-risks (Contingency risks) and RBC risks relate to health plan solvency

Reading 2B: Risk Management in Health Plans

• List some of the factors that may give rise to the assumption of an agency relationship between health plans and their providers

• Discuss some measures a health plan might take to limit the liability associated with credentialing its providers

• Explain some of the ways a risk manager can reduce or eliminate risk exposures related to utilization review • List some of the actions that a risk manager can take in managing the process of providing healthcare in a

health plan environment

Assignment 3: Provider Reimbursement Arrangements

Reading 3A: Provider Reimbursement and Plan Risk

• Discuss the three main drivers of complexity in the healthcare regulatory environment • Describe the influence of the Department of Health and Human Services, the Department of Labor, the Office

of Personnel Management, and the Department of Defense on the healthcare environment • Explain the financial effects that mandated benefit laws and regulations have on health plans

Reading 3B: Provider Reimbursement Methods

• Discuss the advantages and disadvantages of traditional, salary, fee-for service, and discounted fee-for-service provider reimbursement methods

• Explain how utilization risk is distributed in each of the provider reimbursement methods • Define churning, upcoding, and unbundling and recognize which provider reimbursement systems are

designed to solve these problems • Explain the purpose of using the relative value scale and resource-based relative value scale systems • Define global fees, withholds, risk pools, and bonuses and explain how they are used by health plans to

motivate providers to manage overutilization

• Discuss the methods that health plans use to reimburse hospitals

Assignment 4: Capitation and Plan Risk

Reading 4A: Capitation in Provider Reimbursement

• Describe percent-of-premium capitation and PMPM capitation • Explain the differences among and uses of PCP, specialty, full professional, and global capitation

arrangements • Explain how carve-outs are used in conjunction with some capitation contracts • Discuss contact capitation • Describe some of the key information requirements for developing a capitation reimbursement system

Reading 4B: Risk Transfer in Health Plans

• Distinguish between the terms stop-loss insurance and stop-loss reinsurance from the insurance industry perspective

• Explain the differences between specific stop-loss coverage and aggregate stop-loss coverage • Discuss the advantages and disadvantages to a health plan of transferring risk by obtaining stop-loss coverage • Discuss the advantages and disadvantages to a health plan of providing stop-loss coverage to providers and

employer groups

Assignment 5: Fully Funded and Self-Funded Health Plans

Reading 5A: Health Plan Funding

• Distinguish between fully funded and self-funded health plans • Identify and describe the two main types of self-funded health plans

Reading 5B: Alternative Funding Methods

• Distinguish between a contributory plan and a noncontributory plan • Describe the individual components of a premium, including the interest charge, the risk charge, and the

retention charge • List the key characteristics of premium-delay arrangements, reserve-reduction arrangements, minimum-

premium plans, retrospective-rating arrangements, and administrative-services-only contracts

Assignment 6: Financial Aspects of Medicare and Medicaid for Health Plans

Reading 6A: Financial Aspects of Medicare and Medicaid for Health Plans

• Describe the new payment methodology for Medicare • Define the Medicare adjusted community rate (Medicare ACR) and its relationship to the Medicare average

payment rate (Medicare APR) • List the two federal Medicaid law directives to states concerning payment methodology for health plans and

describe some methods used by states to comply with these directives • Describe some of the financial risks for a health plan that provides healthcare services to the Medicare and

Medicaid populations versus the commercial population • List the key features of a state Medicaid program that will determine a Medicaid MCO's level of risk • Describe some of the aspects of health plan’s regulatory environment that impose additional costs on health

plans • Discuss provider reimbursement in Medicare and Medicaid markets

Assignment 7: Rating and Underwriting

Reading 7A: The Relationship between Rating and Underwriting

• Explain the relationship between rating and underwriting • Describe the actuarial function and the underwriting function in a health plan • Discuss the common tiers used in rating methods • Define community rating, manual rating, experience rating, and blended rating, and describe circumstances

under which a health plan would use each method

Reading 7B: Group Underwriting

• Identify the key federal and state laws and regulations that apply to group underwriting • Discuss how a health plan adjusts for morbidity factors and other underwriting risk factors in group

underwriting • Identify and describe the key aspects associated with underwriting the proposed group and the proposed

group coverage

Assignment 8: Small Group Underwriting and Individual Underwriting

Reading 8A: Small Group Underwriting and Individual Underwriting

• List the common characteristics of small group reform laws • Explain the effect of the guaranteed issue provision on the small group markets to which they apply • Define risk pooling as it relates to small group markets • Discuss state reinsurance programs for small group carriers • Identify and describe some characteristics of small groups and individuals that underwrites consider, where

state law permits

Assignment 9: Pricing and Rating

Reading 9A: Pricing a Health Plan

• Describe the relationships among health plan risk, rate-setting, and provider reimbursement • Describe how demand and costs combine to establish the upper and lower limit on pricing a health plan • Explain how an MCO uses underwriting margins, expense margins, and investment margins in its pricing

strategy • Identify and describe rating factors that an MCO uses in developing premium rates for a health plan

Reading 9B: Rate-Setting in Managed Care

• Describe the rate-setting process for HMOs, traditional indemnity plans, PPOs, and plans in a multiple-choice environment

Assignment 10: Accounting and Financial Reporting

Reading 10A: Accounting Principles and Concepts

• Outline main points of the "entity" and "going-concern" concepts with respect to financial reporting in health plans

• Explain the key qualitative factors that affect accounting information and give examples of such factors in health plans

Reading 10B: Principles for Maintaining Accounts

• Discuss the main points in the cost concept, the measuring-unit concept, the full-disclosure concept, and the time-period concept with respect to financial reporting in health plans

• Discuss the realization principle and the matching principle with respect to revenue and expense recognition under generally accepted accounting principles

• Distinguish between accrual-basis accounting and cash-basis accounting

Reading 10C: Financial Statements

• Describe the components and purposes of a health plan's balance sheet, income statement, cash flow statement, and statement of owners' equity

• Explain the importance of notes and supplementary information • Provide an example of the relationships among the various financial statements

Assignment 11: The Strategic Planning Process in Health Plans

Reading 11A: The Strategic Plan

• Define strategic planning, mission statement, and vision statement • Explain the steps in a health plan's typical strategic planning framework • Describe the purpose of a SWOT analysis and list some attributes that health plans evaluate to determine

their strengths, weaknesses, opportunities, and threats

Reading 11B: The Strategic Financial Plan

• Distinguish between a health plan's strategic financial plan and operational budget • Describe the purpose of the financial planning function in for-profit and not-for-profit health plans • Define debt and equity with respect to a health plan’s capital structure • Define cost of capital and the capital asset pricing model • Calculate a health plan's weighted average cost of capital • Explain the purpose of a health plan's pro forma financial statements • List some key drivers of a health plan’s pro forma income statement and balance sheet • Define sensitivity analysis and describe how a health plan uses the optimistic, most likely, pessimistic

scenario modeling and Monte Carlo simulation

Reading 11C: Case Study: Lifelong Health, Inc.

• Apply the concepts discussed in

Readings 11A and 11B in a case study environment

Assignment 12: Financial Statement Analysis in Health Plans

Reading 12A: Financial Statement Analysis

• Differentiate between a health plan's external analysts and internal analysts and describe the types of financial information each one seeks

• Distinguish between horizontal analysis and vertical analysis of a health plan's financial statements • Analyze the trends a health plan exhibits using trend analysis • List and apply the information contained in a common-size financial statement • Explain how to use cash flows that are reported in the cash flow statement to reveal financial information that

is not immediately apparent from a health plan’s balance sheet and income statement

Reading 12B: Fundamentals of Ratio Analysis

• List and apply the financial ratios under U.S. generally accepted accounting principles (GAAP) that fall into each of these four categories: liquidity, activity, leverage, and profitability

• Recognize and apply the ratios that are most important to health plans

Reading 12C: Managed Care-Specific Ratio Analysis

• List and apply to the Annual Statement statutory ratios of liquidity, capital, financial leverage, and profitability (for health plans that must comply with state insurance regulations)

• Recognize and apply the ratios that are most important to health plans

Assignment 13: Management Control

Reading 13A: Management Accounting

• Explain the purpose of management accounting • Identify the distinguishing features of a cost center, profit center, and investment center • Discuss volume-related variances, cost-related variances, and revenue-related variances in a managed care

setting

Reading 13B: Cost Accounting

• Explain the primary uses of cost accounting in managed care • Discuss various ways that costs can be accumulated • Compare the three methods of analyzing costs: change analysis, functional cost analysis, and activity-based

costing

Reading 13C: The Budgeting Process

• Distinguish among top-down budgeting, bottom-up budgeting, and zero-based budgeting • Distinguish among static budgets and flexible budgets, short-term budgets and long-term budgets, and rolling

budgets and period budgets • Itemize the various components of a master budget

Assignment 14: Cash Management and Capitol Budgeting

Reading 14A: Cash Management

• Discuss the fundamentals of cash inflows and cash outflows for a health plan • Analyze a health plan's cash budget using the health plan's cash receipts and cash disbursements

Reading 14B: Capital Budgeting

• Describe the purpose of capital budgeting • Identify the characteristics of the payback method, the discounted payback method, the net present value

method, and the internal rate of return method with respect to a health plan’s capital budgeting decisions • Describe factors that affect a health plan's capital budgeting decisions • Explain the function of sensitivity analysis in capital budgeting

AHM 530: Course Objectives Network Management

This course describes the network management function in a health plan. It covers both network development strategies—risk management, recruiting, selection and contracting—as well as network maintenance strategies— managing provider performance and feedback. Considerations for different types of networks also are addressed. You will learn:

Assignment 1: The Network Management Function

Reading 1A: The Role of Network Management in a Health Plan

• Explain the meaning of network management and list some of the activities that are typically included in this function

• Describe the role of a network management director, a contracting specialist, and a provider relations representative in network management

• Define profiling and explain its significance in network management • Describe some training and support approaches that health plans use to improve the performance of network

management staff • Explain the relationship between network management and medical management, risk management, member

services, and claims administration

Reading 1B: Environmental Considerations for Network Management

• Understand the numerous legislative and regulatory requirements that affect network management • Identify the expectations of purchasers and consumers with respect to network management • Describe how health plans balance complex and sometimes competing interests and requirements in

managing provider panels

Assignment 2: Strategies for Network Development and Management

Reading 2A: Analysis of Market and Health Plan Needs

• Explain how the presence of provider organizations and the level of market maturity affect network strategies • Explain how a health plan can use a competitive analysis to determine the size of the network • Describe some differences between network needs for large employers and needs for small employers • Describe some of the challenges that health plans face when developing networks in rural areas • List several different areas for which a health plan should establish goals before beginning to develop or

revise a provider network

Reading 2B: Considerations for the Structure, Composition, and Size of the Network

• Explain how a network-within-a-network approach can benefit a health plan with more than one product in a market

• Explain the difference between primary care HMOs and open access HMOs • List several sources of laws, regulations, or guidelines on network access and adequacy • Explain how a tiered network helps a health plan address the cost-access trade-off that health plans typically

encounter when setting the size of the provider panel • Describe the "build or buy" decision for networks and list some reasons why a health plan might lease a

network or outsource development of a network

Reading 2C: Delegation of Network Management Activities

• Define delegation and sub-delegation • Explain the difference between "authority" and "accountability" with regard to delegation

• List some reasons why health plans sometimes delegate activities • Identify and describe the steps in the delegation process • Describe the primary requirements of the National Committee for Quality Assurance (NCQA) and the

American Accreditation HealthCare Commission (the Commission/URAC) for demonstrating appropriate oversight of credentialing delegation

Assignment 3: Selecting Network Providers

Reading 3A: Identifying and Recruiting Providers for a Health Plan Network

• List and describe the types of providers included in the most managed care networks • Discuss the factors that a health plan considers when identifying potential network hospitals and practitioners • Explain the advantages and disadvantages of health plan contracting with individual practitioners and

provider organizations • Discuss the methods that health plans may use to recruit candidates for their provider networks

Reading 3B: Collecting and Verifying Data for Credentialing Purposes

• Explain the data collection and verification processes used in credentialing and describe their importance to a health plans selection of network physicians

• Describe the role played in data collection and verification by: • American Board of Medical Specialties (ABMS) • Federation of State medical Boards • National Practitioner Data Bank (NPDB) • Healthcare Integrity and Protection Data Bank (HIPDB) • provider profiling • Explain the liability issues involved with credentialing decisions, including: requirements of the Americans

with Disabilities Act (ADA), confidentiality, vicarious liability, violation of due process, and negligent credentialing

• Describe how and why health plans delegate credentials verification to third parties • Describe the data collection and verification services provided by hospitals and medical facilities, Physician

Organization Certification (POC) program, and credentials verification organizations (CVOs)

Assignment 4: Provider Contracting: Part One

Reading 4A: The Provider Contract

• Explain why health plans enter into legal contracts with providers • Describe the essentials elements of a contractual relationship • Identify the differences and similarities between a comprehensive and a brief provider contract • Describe the major elements in a comprehensive contract • Discuss the goals that a health plan may try to reach through its contractual strategies

Reading 4B: The Negotiation Process for Provider Contracting

• List some circumstances that may result in renegotiation of a provider contract • List and describe some of the functions that are often represented on health plan and provider negotiating

teams • Describe some types of information that the health plan typically seeks about a provider, and vice versa,

when preparing for provider contract negotiation • Describe the process for setting objectives for negotiation

Assignment 5: Provider Contracting: Part Two

Reading 5A: Responsibilities of Health Plan and Providers Under Provider Contracts

• Describe a low-enrollment guarantee clause and explain how health plans use low-enrollment guarantee clauses in capitated contracts

• Explain two situations in which health plans modify existing provider contracts and two methods of modification

• Describe the issues about physician/patient communication that may be of concern to providers • List several reasons why a contract with a primary care provider should describe the scope of service in detail • List and describe three types of termination clauses • Explain the role of the due process clause in the termination of providers

Reading 5B: Compensation Arrangements Between Health Plans and Providers

• Explain how an MCO transfers financial risk to providers through reimbursement arrangements • Describe the primary advantages and disadvantages of fee-for-service, salary, and capitation payment

systems • List and describe four types of capitation • Explain how health plans use incentives in compensation arrangements • List and describe four ways to manage a provider's financial risk • Describe some factors that influence the way a health plan compensates its providers

Assignment 6: Network Management Considerations for Different Types of Providers

Reading 6A: Strategies for the Specialist Component of the Provider Network

• Describe some of the challenges health plans face when contracting with hospital-based specialists • Describe the different reimbursement options that health plans typically use for specialists • Discuss some common problems that health plans encounter when using capitation for specialty care

Reading 6B: Strategies for Contracting with Hospitals and Subacute Care Facilities

• Explain why health plans sometimes contract with centers of excellence • List issues that a health plan considers when selecting a center of excellence • List and describe methods that health plans commonly use to reimburse hospitals for inpatient and outpatient

services • Define ambulatory payment classifications (APCs) and compare this system to diagnosis-related groups

(DRGs) • Explain why health plans contract with facilities for subacute care and describe the main criteria for selecting

subacute care providers

Reading 6C: Pharmacy Networks

• Describe the advantages early pharmacy networks had over direct pay and cost-sharing pharmacy systems • Identify the features that distinguish pharmacy networks from other health plan networks • Describe the impact of pharmacy benefits management in managed care • Explain the advantages and disadvantages of maintaining in-house management of pharmacy benefits or

outsourcing benefits through a pharmacy benefit management company (PBM) • Describe the options available for delivering pharmacy services • Identify the methods that health plans and PBMs use to reimburse network pharmacies

Reading 6D: Considerations and Strategies for Specialty Services

• Explain some of the different carve-out arrangements that an MCO may use to arrange access to specialty services

• Describe the criteria a health plan uses to select a sole-source provider for specialty services • Explain how the role of the PCP in behavioral healthcare varies among health plans • Explain a health plan’s options for arranging access to clinical eye care and routine eye care • Distinguish between ophthalmologists, optometrists, opticians • List some reasons health plans often find the development and management of alternative healthcare

networks to be challenging • List some ways in which a home healthcare agency can prepare itself to accept capitated contracts

Assignment 7: Establishing Networks for Government-Sponsored Programs

Reading 7A: Special Considerations for Medicare Networks

• Identify federal legislation that has affected the Medicare program and describe its impact on Medicare health plans

• List the three types of health plans that are authorized to apply for Medicare contracts under the Medicare + Choice programs, and identify the two types of health plans that are allowed to establish closed networks of providers

• Describe the steps that Medicare + Choice health plans must take to ensure that network services are available and accessible to enrollees

• Describe the restrictions on the use of physician incentive plans by Medicare + Choice health plans • Discuss several other HCFA regulations affecting the relationship between Medicare + Choice health plans

and network providers • Discuss some special needs of Medicare beneficiaries that health plans should consider when establishing

Medicare networks

Reading 7B: Special Considerations for Medicaid Networks

• Explain the origin and purpose of the Medicaid program • Describe the characteristics of the three major segments of the Medicaid population and the challenges these

groups present for health plans • Define a safety net provider and explain the role that safety net providers can play in Medicaid managed care • Define the two types of Medicaid managed care entities (MCEs)- managed care organizations (MCOs) and

primary care case managers (PCCMs) • Explain the differences between open contracting and selective contracting • Discuss some of the challenges that health plans face in applying managed care strategies to Medicaid • Describe the type of information a health plan might include in its response to a Medicaid Request for

Proposal (RFP) • Explain some of the important considerations in a Medicaid-MCO managed care contract • List some of the questions a health plan might ask when credentialing providers for a Medicaid network • Discuss the compensation of Medicaid providers, including creative compensation methods that health plans

can use

Reading 7C: Provider Networks for Workers' Compensation

• Explain why a state might want to institute managed workers' compensation • Explain why the selection process for workers' comp providers differs from that for other types of networks • Describe some of the nonfinancial tools that a health plan can use to manage the performance of its workers'

comp providers

Assignment 8: Ongoing Management of Provider Networks

Reading 8A: Continuing Management of Network Adequacy and Provider Satisfaction

• Describe some situations that may indicate a need to review network adequacy

• List several factors that health plans examine when reassessing access and availability • Explain the importance of provider retention • Describe several methods that health plans use to provide continuing education to network providers and

their staff • Explain how direct referral and self-referral programs assist providers with utilization management • List some of the issues that a health plan typically addresses through surveys of providers and their staffs • Explain why health plans often seek to involve network providers in network management and medical

management operations

Reading 8B: Managing Provider Performance

• Explain why health plans measure the performance of network providers • Describe how provider profiling is important in performance measurement and performance management • Describe the following types of performance measures:

o Structure o Process o Outcomes o Patient satisfaction

• Explain how outcomes research and outcomes measurement can be used to benchmark provider performance • Describe some of the methods health plans can use to change provider behavior

AHM 540: Course Objectives Medical Management

This course explores medical policy and technology evaluation, authorization systems, focused strategies for utilization management, accreditation, quality management methods, and the legal aspects of utilization and quality management. You will learn:

Assignment 1: The Medical Management Function

Reading 1A: The Role of Medical Management in a Health Plan

• Define the term medical management and explain the goals of this function • Describe some common components of medical management programs • Describe the role of the medical director in a health plan • Explain the purpose of medical management committees and identify several common types of medical

management committees • Define the terms delegation and subdelegation • Explain why health plans sometimes delegate medical management activities

Reading 1B: The Relationship of Medical Management to Other Health Plan Functions

• Explain the relationship between medical management and each of the following health plan departments: • Network management • Risk management • Legal affairs • Claims administration • Finance • Sales and marketing • Understand the role of information management in medical management operations and reporting • Describe some of the technologies that health plans use to manage information

Reading 1C: Environmental Influences on Medical Management

• Describe the types of environmental factors that affect medical management programs of health plans

• Discuss the expectations of purchasers, providers, and plan members for medical management • Describe the major federal and state regulatory requirements that affect medical management • Describe how environmental factors influence a health plan's delegation of medical management functions • Identify the main accrediting agencies and explain the impact of accreditation on medical management

Assignment 2: Clinical Practice Management

Reading 2A: Clinical Practice Management

• Describe the components of a health plan’s coverage policy • List several types of services that health plans typically limit or exclude • Describe the types of coverage issues typically addressed by medical policy • Explain the importance of technology assessment as it relates to medical policy • Explain the role of clinical practice guidelines

Assignment 3: Quality Management in Health Plans

Reading 3A: Quality Management

• Describe the major steps in the quality management process • Describe the role of outcomes in quality management • Identify the characteristics, uses, and sources of quality standards • Describe the differences between traditional healthcare and population-based healthcare • Describe how quality management relates to risk management and information management

Reading 3B: Quality Assessment

• Describe the major components of a quality assessment program • Describe the methods health plans use to identify and prioritize key services and processes • Identify the types of standards and indicators used in performance measurement • Identify the three main types of performance measures and describe their advantages and disadvantages • Explain the importance of case mix/severity adjustment • Describe the types and sources of data needed to measure performance • Describe the use of plan and provider report cards • Identify some of the major issues and barriers in performance measurements

Reading 3C: Quality Improvement

• Identify the major components of the performance improvement cycle • Describe how health plans use benchmarking to guide quality improvement activities • Identify the goals of member education and outreach programs • Describe the techniques health plans use to improve providers' ability to work within the healthcare system • Describe three tools health plans can use to support provider decision making and improve clinical

performance

Assignment 4: Preventive Care, Self-Care, and Decision Support Programs

Reading 4A: Preventive Care Programs

• Identify the three levels of preventive care • Explain the role of health risk assessment (HRA) for preventive care • Describe some strategies that health plans may use to enhance member participation in preventive care

programs

Reading 4B: Self-Care and Decision Support Programs

• Describe the use of telephone triage services in self-care and decision support programs • Identify general methods that health plans use to evaluate the effectiveness of preventive care, self-care, and

decision support programs • Discuss the use of integration and partnerships to improve preventive care, self-care, and decision support

programs

Assignment 5: Utilization Review

Reading 5A: Utilization Review

• Discuss some of the key issues health plans must address to develop and maintain effective utilization review programs

• Explain the importance of medical necessity, medical appropriateness, and utilization review process • Describe the role of authorizations and member appeals in the utilization review process • Identify some of the ways that health plans evaluate the results of utilization review programs

Assignment 6: Case Management

Reading 6A: Case Management

• Describe a variety of case management activities • Explain the steps of the case management process • Identify several strategic issues that may affect the development and improvement of case management

programs • Discuss the impact of legal issues, regulations, and accrediting agencies on case management functions

Assignment 7: Disease Management

Reading 7A: Disease Management

• Distinguish between disease management and case management • Explain why health plans establish disease management programs • Describe the types of organizations that provide disease management • Explain the decisions a health plan must make to implement a disease management program • Describe four approaches to integrating information disease management programs

Assignment 8: Medical Management Considerations for Different Levels of Care

Reading 8A: Medical Management Strategies for Acute Care

• Describe the potential benefits and drawbacks of using hospitalists for the management of inpatient acute care

• Explain why the utilization of emergency services is an ongoing concern for health plans and describe some approaches that health plans may use to improve utilization management for emergency care

• Explain how clinical pathways are useful medical management tools and how health plans facilitate development of them

• Define the term center of excellence and describe how its use may benefit health plan medical management programs

Reading 8B: Medical Management Strategies for Post-Acute Care

• Identify and describe the purposes of four types of post-acute care • Explain how subacute care differs from skilled care • Explain two types of advance directives • Describe the role of a health plan in end-of-life care

Assignment 9: Medical Management Considerations for Pharmacy and Specialty Services

Reading 9A: Medical Management for Pharmacy Services-Part I

• Describe some of the advantages and disadvantages of using pharmacy benefit managers (PBMs) to develop and manage pharmacy benefit programs

• Identify strategies that health plans can use to manage the way medications are priced and prescribed • Describe three factors that impact prescription drug utilization • Explain the difference between a two-tier and a three-tier copayment structure • Describe five different types of analyses that are conducted in pharmoeconomic research

Reading 9B: Medical Management for Pharmacy Services-Part II

• List several functions that a health plan's pharmacy and therapeutics (P&T) committee performs • List the five steps in performing DUR • Describe the three types of DUR • Explain the state laws related to mail-order pharmacies and generic substitution

Reading 9C: Medical Management for Specialty Services

• Explain why a health plan might choose to use a carve-out arrangement to deliver a specialty service • Describe several medical management challenges for behavioral healthcare • Explain the strategies that health plans and managed behavioral healthcare organizations use to manage

quality and costs for behavioral healthcare • Understand quality and utilization management strategies for dental care, vision care, and complimentary and

alternative medicine

Assignment 10: Medical Management for Government-Sponsored Programs

Reading 10A: Medicare

• Identify the major benefits of managed Medicare • Understand the legal and regulatory requirements that affect medical management for Medicare • Recognize the special health risk factors and needs of the Medicare population • Describe the important components of a comprehensive program of geriatric care

Reading 10B: Medicaid

• Describe the impact of recent laws and regulations on the management of medical care for Medicaid recipients

• Describe the health risk factors and healthcare needs of Medicaid recipients • Identify the essential components of an effective Medicaid managed health care plan • Describe the challenges health planss face in designing programs to meet the needs of Medicaid recipients

Reading 10C: Other Government-Sponsored Healthcare Programs

• Identify several FEHBP requirements that impact a health plan's medical management activities

• Describe how the Military Health System and the Veterans Health Administration influence healthcare quality and cost in the private sector, and vice versa

• Discuss key differences between workers' compensation programs and group healthcare programs in terms of quality management and cost management.