ESSENTIALS OF MANAGED HEALTH CARE - PART 4A: OPERATIONAL MARKETING AND MANAGEMENT

Course overview

OBJECTIVES Section 1: INFORMATION SYSTEMS IN MANAGED HEALTH CARE PLANS 1. Describe key attributes for the information systems area in an MCO. Relate the four operational competencies of informational systems for MCOs. 2. Explain several advantages of EDI. 3. Explain the provisions set forth by HIPAA to protect confidentiality and privacy. 4. Illustrate the four main privacy-related corporate compliance functions required under HIPAA. 5. List the three administrative compliance requirements under HIPAA. 6. Define HEDIS and explain its use. Section 2: CLAIMS AND BENEFITS ADMINISTRATION 1. Relate the five purposes of benefits administration and claims adjudication within a managed care organization. 2. Describe how the claims process can be a key contributor to a plan's quality improvement program. 3. List the three (3) measures of claims quality. 4. Describe the four (4) key opportunities offered by the claims and benefits administration department. 5. Name the five (5) elements that contribute to the effectiveness of claims operations management. 6. Explain why inventory control is important and describe the four (4) management steps that contribute to inventory control. 7. Describe the responsibilities involved in productivity management. 8. Explain the relationship between productivity standards and turnaround times. 9. List the seven (7) business functions included in the claims process. 10. Discuss the problems common to claims and benefit administration. 11. List the three kinds of claims policy and procedure. 12. Define the three sources for definitive interpretation of benefits that determine plan liability when adjudicating a claim. 13. Name five areas or functions that claims departments most often coordinate with and describe the issues that are coordinated. Section 4: SALES AND MARKETING IN MANAGED HEALTH CARE PLANS: THE PROCESS OF DISTRIBUTION 1. Describe the most common challenges facing sales and marketing in managed health care. 2. Discuss how the health plan manages its challenges. 3. List the seven (7) key needs that drive employer choice. 4. Describe the six key criteria upon which consumers base their health plan choices. 5. Describe the key positions within a sales and marketing organization and how they must interact with each other. 6. Describe the various forms of advertising that a health plan might use, and the situations and environments in which the use of each form would be appropriate. Section 5: THE EMPLOYER'S VIEW OF MANAGED HEALTH CARE: SHOW ME THE VALUE 1. Rank the five (5) managed care trends affecting large employers in order of importance. 2. Describe how this ranking would differ if it were a small employer. 3. Define value as it relates within the health care field. 4. Discuss how the apparent move toward individual consumerism impact: a. the large employer, b. the small employer c. the national health plans 5. List the eight (8) main trends likely to figure largely in the future of managed health care. 6. Discuss the value in e-health business to consumer companies or business to business companies.