Refer to Syllabus

Course Description

A pragmatic examination of the theories for and uses of managed health in the 21^st century. Special emphasis is placed on the structure of care delivery in hospitals, community health clinics, and medical practices. The impact of the ACA on health insurance is also reviewed.

Through the text readings, instructor notes, articles, videos, tests, written assignments, and discussions the student will:

1.            Understand foundations of the American managed health care system including a historical overview of managed care and organizational structures, concepts, and practices of the managed care industry. Understand the following: how health insurance and managed care came into being, the forces that helped to shape the industry, major obstacles to managed care historically, and major forces shaping health insurance and managed care today.

2.            Understand the core components of health benefits including coverage and risk bearing responsibilities, types of health insurers and managed care organizations, and distinct types of payers. The ACA will be examined.

3.            Understand components of the provider network including basic elements of contracts, service areas and access standards, and basic credentialing. Gain knowledge of networks for physicians, hospitals, integrated healthcare delivery systems, and ancillary services.

4.            Understand the difference between payment and reimbursement, standardized electronic transaction code sets used for billing and payment, and elements of risk and non-risk-based provider payment. Be familiar with the most common forms, modifiers, and variations of payment for physician services, hospitals, ancillary services, and others. Be familiar with payment that combines hospital and physician payment and the basics of value-based payment (VBP) and pay for performance (P4P).

5.            Recognize the different approaches to managing wellness and prevention. Identify and describe the basic metrics and measures used to assess and monitor health plan medical costs and utilization. Describe the basic components of utilization management for medical services, including prospective, concurrent, and retrospective review. Explain the basic concepts of quality management, including structure, process, and outcome. Understand the purpose and scope of external review and accreditation of managed care plans.

6.            Describe the basic structure of governance and management in payer organizations. Know internal operations of payer organizations: IT, marketing and sales, insurance exchanges, underwriting and premium rate development, eligibility and enrollment, billing and claims, benefit administration, and member services including appeal rights. Be familiar with statutory accounting and statutory net worth, financial management, and the common potential problems and challenges faced by payers.

7.            Explain the Medicare benefit structure including the basic elements and requirements for private Medicare Advantage and Medicaid plans. Explain the difference between plans serving the typical Medicare and/or Medicaid population and those serving beneficiaries who have special needs and/or who are “dual eligibles.” Understand key regulatory issues in government entitlement programs that affect private managed care plans. Understand the unique key aspects of how Medicare pays Medicare Advantage plans. Explain at a high level the basics of the Medicare Quality Bonus Payment Program, also called Medicare Stars or simply Stars.

8.            Understand significant state and federal laws impacting health insurance and managed care. Describe the basic structure of state and federal oversight of managed care organizations (MCOs). Explain the interaction of state and federal laws impacting payers. Demonstrate understanding in the oversight and regulation of payer organizations.

9.            Understand health insurance and managed care on a practical level to assist in achieving future career goals. 

Grades will be comprised of discussions, papers, and exams. Assignments will be from the text book, discussion topics, papers and tests, and articles and videos in the D2L module.

See syllabus for rules against cheating, collusion, misconduct, AI usage, and plagiarism. See syllabus for online computer requirements and student expectations.

This is an online class. Regular and timely online classroom discussion is required. Submission of assignments and online tests is required by the due dates. The instructor must give the student a verbal or written warning prior to being dropped from the class. Instructor records will stand as evidence of absences and failure to do the work. 

All assignments must be turned in on time or the student will normally receive a grade of zero (0). 

Note: You may not submit a paper for a grade in this class that already has been (or will be) submitted for a grade in another course, unless you obtain the explicit written permission of me and the other instructor involved in advance.

Plagiarism is the use of someone else's thoughts, words, ideas, or lines of argument in your own work without appropriate documentation (a parenthetical citation at the end and a listing in "Works Cited")-whether you use that material in a quote, paraphrase, or summary. It is a theft of intellectual property and will not be tolerated, whether intentional or not.

Student Honor Creed

As an MSU Student, I pledge not to lie, cheat, steal, or help anyone else do so."

As students at MSU, we recognize that any great society must be composed of empowered, responsible citizens. We also recognize universities play an important role in helping mold these responsible citizens. We believe students themselves play an important part in developing responsible citizenship by maintaining a community where integrity and honorable character are the norm, not the exception.

Thus, We, the Students of Midwestern State University, resolve to uphold the honor of the University by affirming our commitment to complete academic honesty. We resolve not only to be honest but also to hold our peers accountable for complete honesty in all university matters.

We consider it dishonest to ask for, give, or receive help in examinations or quizzes, to use any unauthorized material in examinations, or to present, as one's own, work or ideas which are not entirely one's own. We recognize that any instructor has the right to expect that all student work is honest, original work. We accept and acknowledge that responsibility for lying, cheating, stealing, plagiarism, and other forms of academic dishonesty fundamentally rests within each individual student.

We expect of ourselves academic integrity, personal professionalism, and ethical character. We appreciate steps taken by University officials to protect the honor of the University against any who would disgrace the MSU student body by violating the spirit of this creed.

Written and adopted by the 2002-2003 MSU Student Senate.

The Americans with Disabilities Act (ADA) is a federal anti-discrimination statute that provides comprehensive civil rights protection for persons with disabilities. Among other things, this legislation requires that all students with disabilities be guaranteed a learning environment that provides for reasonable accommodation of their disabilities. If you believe you have a disability requiring an accommodation, please contact the Disability Support Services in Room 168 of the Clark Student Center, (940) 397-4140.

The professor considers this classroom to be a place where you will be treated with respect as a human being - regardless of gender, race, ethnicity, national origin, religious affiliation, sexual orientation, political beliefs, age, or ability. Additionally, diversity of thought is appreciated and encouraged, provided you can agree to disagree. It is the professor's expectation that ALL students consider the classroom a safe environment.

All instructors in the Department have voicemail in their offices and MSUTexas e-mail addresses. Make sure you add your instructor's phone number and e-mail address to both email and cell phone lists of contacts.

Obligation to Report Sex Discrimination under State and Federal Law

Midwestern State University is committed to providing and strengthening an educational, working, and living environment where students, faculty, staff, and visitors are free from sex discrimination of any kind. State and federal law require University employees to report sex discrimination and sexual misconduct to the University’s Office of Title IX. As a faculty member, I am required to report to the Title IX Coordinator any allegations, personally observed behavior, or other direct or indirect knowledge of conduct that reasonably may constitute sex discrimination or sexual misconduct, which includes sexual assault, sexual harassment, dating violence, or stalking, involving a student or employee. After a report is made, the office of Title IX will reach out to the affected student or employee in an effort to connect such person(s) with resources and options in addressing the allegations made in the report. You are also encouraged to report any incidents to the office of Title IX. You may do so by contacting:

Laura Hetrick

Title IX Coordinator
Sunwatcher Village Clubhouse
940-397-4213

laura.hetrick@msutexas.edu

You may also file an online report 24/7 at Maxient 

Should you wish to visit with someone about your experience in confidence, you may contact the MSU Counseling Center at 940-397-4618. For more information on the University’s policy on Title IX or sexual misconduct, please visit MSU Texas Title IX

Senate Bill 11 passed by the 84th Texas Legislature allows licensed handgun holders to carry concealed handguns on campus, effective August 1, 2016. Areas excluded from concealed carry are appropriately marked, in accordance with state law. For more information regarding campus carry, please refer to the University’s webpage at https://msutexas.edu/campus-carry/rules-policies.

If you have questions or concerns, please contact MSU Chief of Police at police@msutexas.edu.