HSM 420 – Managed Care and Health Insurance

HSM 420 Complete Discussions Week 1 – 7

HSM 420 Week 1 Discussion Question 1 – Indemnity Versus Managed Care
HSM-420 Week 1 Discussion Question 2 – Managed Care Impacts

HSM 420 Week 2 Discussion Question 1 – Provider Networks
HSM-420 Week 2 Discussion Question 2 – Legal Issues in Provider Contracting

HSM 420 Week 3 Discussion Question 1 – Provider Networks
HSM-420 Week 3 Discussion Question 2 – Legal Issues in Provider Contracting

HSM 420 Week 4 Discussion Question 1 – Managed Care Pharmacy Benefits
HSM-420 Week 4 Discussion Question 2 – Managed Behavioral Healthcare

HSM 420 Week 5 Discussion Question 1 – Managed Care Accreditation
HSM-420 Week 5 Discussion Question 2 – Managed Care Marketing

HSM 420 Week 6 Discussion Question 1 – Fraud and Abuse
HSM-420 Week 6 Discussion Question 2 – Underwriting and Rating

HSM 420 Week 7 Discussion Question 1 – State and Federal Regulation
HSM 420 Week 7 Discussion Question 2 – Patient Protection and Affordable Care Act

HSM 420 Week 4 Midterm

  1. (TCO 1)Why were the first proto-HMOs formed in America? What were the original driving factors in the HMO movement?
  2. (TCO 1)What is meant by indemnity coverage, and how does it change in managed indemnity?
  3. (TCO 2) What is the role of the executive director in a managed care organization? Could you see yourself practicing in this position at some point in your career?Why or why not?
  4. (TCO 2) What is the role of the Peer Review Committee in a managed care organization? And why is this function so crucial?
  5. (TCO 3) Describe the calculation of capitated payments. How are these rates determined in managed care organizations?
  6. (TCO 3) Describe the use of evidence-based clinical criteria in managed care. Why is this process so important in managed care today?
  7. (TCO 4) What is meant by pattern review under managed care? Why do payers conduct pattern review, and what kinds of things might they identify during such reviews?
  8. (TCO 4) Discuss some key general aspects of physician practice behavior? Include implicit messages from training, and also environmental factors, in your answer.
  9. (TCO 7) What is the purpose of hold-harmless and balance-billing clauses in managed care contracts?
  10. (TCO 7) What is typically covered under “term, suspension, and termination” of a managed care contract?

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