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

Course overview

OBJECTIVES Section 1: THE IMPACT OF CONSUMERISM ON MANAGED HEALTH CARE 1. List and describe the seven (7) primary drivers of health care consumerism and explain why each is significant. 2. Define the four (4) major implications of health care consumerism on managed care organizations. 3. Discuss the four (4) basic elements involved in the process of developing consumer strategies. Section 2: ACCREDITATION AND PERFORMANCE MEASUREMENT PROGRAMS FOR MANAGED CARE ORGANIZATIONS 1. Name five elements (areas of review) in an accreditation program. 2. Explain the process involved in accrediting a managed care organization. 3. Define and differentiate between accreditation and certification. 4. Define HEDIS and the areas covered by HEDIS. 5. List the six main categories covered in the URAC standards. 6. List the eight (8) standards covered by the Joint Commission in the process of its accreditation. Section 3: COMMON OPERATIONAL PROBLEMS IN MANAGED HEALTH CARE PLANS 1. Discuss the operational problems common to MCOs. 2. Define adverse selection and its potential effects on MCOs. 3. Discuss what steps a medical director should take to prevent anticipated problems with the delivery system and the risks involved in hose steps. 4. Explain what monitoring activities might an HMO chief executive officer take to prevent his/her plan from falling prey to a serious but common problem. Section 4: OPERATIONAL FINANCE AND BUDGETING 1. Describe what regulatory agencies or organizations govern HMOs and describe the different aspects of their governance. 2. Identify the varied populations whose interests must be addressed by financial managers. 3. Explain how the profit and loss and forecast information should be segregated and why. 4. List and explain the five (5) key components of financial statements. 5. List and describe the seven (7) basic elements of a balance sheet. 6. Describe the key elements an HMO finance officer needs to properly set the claims accruals. 7. Define a lag report and explain what are completion factors. 8. Explain the strengths and problems associated with completion factors. 9. Explain how premiums are billed and received. 10. Explain premium deficiency and review why it's identification is important, and how should this be reflected in the accounting records. 11. Describe how enrollment affect the financial statement components. 12. Discuss the accounting issues and challenges related to risk pool arrangements entered into with providers. 13. Define: a. risk-based capital b. statutory accounting edit delete 14. Differentiate between statutory accounting principles and generally accepted accounting principles and explain why this is important to an HMO. 15. Review some of the recent changes in statutory reporting requirements. Section 5: UNDERWRITING AND RATING FUNCTIONS COMMON TO MOST MARKETS 1. Differentiate between rating and underwriting. 2. Describe the four (4) basic forms of premium rates used by MCOs. 3. Describe the twelve (12) basic elements that go into typical rate development formulas. 4. List the four (4) points in an employer group's lifecycle when underwriting can occur.