CM 580
MANAGED HEALTH CARE
course information
This is the fifth and last course in the case management continuing education program. This comprehensive course focuses on managed health care. The course provides participants with a comprehensive study of the history, development and implementation of managed health care systems. Students will study all facets of managed care, including structure, functions and implications for overall health care delivery. All models of managed care are reviewed. Participants will study legal issues as well as regulatory issues relevant to managed care and models of managed health care. Other issues presented include personnel issues, quality issues, evaluation of care models and systems and roles of health care professionals within managed health care models and systems. The insurance industry is examined and students will study all of the current reimbursement systems in place, including commercial and government funded and administered. This is an advanced course in the case management education program. Course content is of a more complex nature and requires learning of more complex materials. Course Code: CM 580. Contact hours of education = 60.
This course is particularly designed for those who would like to apply for Fellowship certification as a "Fellow" in the American Academy of Case Management.
This is a guided, independent study CEU Course. You are to study and progress at your own rate.
There is one comprehensive examination for this course.
Instructor/Course Author: Dominick L. Flarey, Ph.D, MBA, RN-BC, CNAA, FACHE
Link to Resume
E-mail: info@aihcp.org
TIME FRAME: You are allotted two years from the date of enrollment, to complete all of the courses in this continuing education program (all five (5) courses). There are no set time-frames per course, other than the two year allotted time. If you do not complete the courses within the two-year time-frame, you will be removed from the course and an "incomplete" will be recorded for you in our records. Also, if you would like to complete the courses after this two-year expiration time, you would need to register and pay the course tuition fee again.
TEXTBOOK
Essentials of Managed Health Care, 5th edition, by: Peter R. Kongstvedt. Jones and Bartlett Publishers, 2007. ISBN-10: 0763739839 ISBN-13: 978-0763739836
AIHCP Online Bookstore: AIHCP provides an online bookstore stocked with all of the required textbooks, and/or materials required for its CE courses. To purchase this book online, click the access store link, go to the table of categories, right upper hand corner, and click on Case Management. Access AIHCP Store: click here
BOARD APPROVALS: AIHCP is an approved provider of continuing education by the Florida Board of Nursing and the District of Columbia Board of Nursing. CE Provider # 50-11975. The American Institute of Health Care Professionals, Inc. is a licensed Continuing Education Provider in the State of California, Board of Registered Nursing, Provider # CEP 15595. Access information
Online Classroom Resouces and Tools
* Message Boards: each specialty program has an area to "post" on the message board. Students may post messages at anytime. Posting allows students to converse with those in the same specialty practice and to discuss issues/course content etc. Instructions for posting are provided in the online classrooms.
* Chat Rooms: each specialty has it's own unique "chat room." Inside of the classroom there is a schedule for "chat time" with students in your specific specialty practice. Participating in "chats" is voluntary. The chat sessions are used as means for students to come together and discuss course content or anything related to the courses and/or certification specialty.
* Examination Access: there is link to take you right to the online examination program where you can print out your examination and work with it. All examinations are formatted as "open book" tests. When you are ready, you can access the exam program at anytime and click in your responses to the questions. Full information is provided in the online classrooms.
* Student Resource Center: there is a link for access to a web page "Student Resource Center." The Resource Center provides for easy access to all of our policies/procedures and additional information regarding applying for certification. We also have many links to many outside reference sites, such as online libraries that you may freely access.
* Online Evaluation: there is a link in the classroom where you may access the course evaluation. All students completing a course, must, without exception, complete the course evaluation.
* Faculty Access Information: you will have access to your instructor's online resume/biography, as well as your instructor's specific contact information.
* Additional Learning Materials: some faculty have prepared additional "readings" and /or brief lecture notes to enhance your experience. All of these are available in the online classrooms.
Blog of the American Academy of Case Management: access here
Blog of the American Academy of Case Management: Please be sure to visit our Blog. Participation is encouraged.
Fellowship Certification Information:
Once you have completed all of the five (5) courses in this education program, you are eligible for application and conferral of "Fellowship status and Certification" in the American Academy of Case Management. To access program information on Fellowship/Certification, click here.
COURSE OBJECTIVES:
Upon completion of this course, you will be able to:
1. Define and discuss theories and models of managed care.
2. Understand and discuss the various types of managed care organizations.
3. Define and understand the structure and process of integrated health care delivery systems.
4. Review complimentary and alternative health care modalities.
5. Define the common assertions/myths and facts about managed health care.
6. Discuss and define several types of health care delivery systems.
7. Review and discuss primary health care models as used in managed care plans today.
8. Review models of compensation in primary care models.
9. Discuss structures and processes for contracting with specialty physicians.
10. Discuss structures for reimbursement systems for physicians.
11. Discuss issues related to negotiations and contracting with health care providers.
12. Review concepts, structure and processes of care management models.
13. Discuss the management of medical and surgical care utilization review.
14. Define types of clinical services requiring managed care authorizations.
15. Compare and contract managed care and case management.
16. Review and apply the core concepts of disease management.
17. Discuss prescription and drug benefit plans in managed care.
18. Define core issues related to the delivery of behavioral health care in managed care.
19. Review major concepts of quality management within managed care models.
20. Define and discuss how managed care has affected physician behavior and practice patterns.
21. Discuss major uses for information systems in managed care.
22. Define and discuss the structure and processes of claims administration.
23. Review and define the major structure of managed care models in the Medicare program.
24. Define models of managed care used in state Medicaid programs.
25. Define and discuss the major legal issues and challenges in managed care today.
26. Define and discuss HIPPA and its requirements and place in managed health care.
27. Define and discuss new care initiatives in the Medicare program today.
Course content
Types of Managed Care Organizations
Integrated Health Care Delivery Systems
Complementary and Alternative Medicine: An Introduction to Modalities
Elements of the Management Control and Governance Structure
Examining Common Assertions about Managed Care
Health Care Delivery Systems
Primary Care in Managed Health Care Plans
Compensation of Primary Care Physicians
Contracting and Reimbursement of Specialty Physicians
Negotiating and Contracting with Providers
Care Management and Clinical Integration Components
Managing Medical-Surgical Utilization
Clinical Services requiring Authorization
Case Management and Managed Care
Fundamentals and Core Competencies of Disease Management
Prescription and Drug Benefits in Managed Care
Managed Behavioral Health Care and Chemical Dependency Services
Quality Management in Managed Care
Using Data and Provider Profiling in Medical Management
Physician Behavior Change in Managed Health Care
Information Systems in Managed Health Care Plans
Claims and Benefits Administration
Medicare and Managed Care
Medicaid Managed Care
Legal Issues in Managed Care
HIPPA