HIM 1300 – Health Care Facilities/Delivery Assignments Complete Read chapter 9 Managed Care of textbook

HIM 1300 – Health Care Facilities/Delivery Assignments Complete Read chapter 9 Managed Care of textbook

Read materials and complete the following in order for Managed Care: o Managed Care Introduction o Managed Care PowerPoint o Health Insurance (video) o Medicaid (video) o Pay for Performance o Genetic Testing

Complete Study:

1. In the managed care arena, what is capitation? Who are the “Gatekeeper” and their duties?

2. What are the alternative(s) to managed care? For Americans, what issues does managed care raise?

3. How do PPOs differ from HMOs?

4. Provide information on the HEDIS abbreviation, purpose, its responsibility to consumers,

and its effects on quality in healthcare. Surf the Internet.

5. Continue your search to report on HEDIS to offer information and compare managed

care providers. Go to: http://www.ncqa.org Search the website to learn about the data elements. Your goal will be to access performance for HEDIS Measures Effectiveness of Care: a. Use the 2016-2020 Quality Measurement Report to briefly summarize the chronic diseases measured for:

• Adult BMI Assessment

• Lead Screening

• Cervical Cancer

6. Research Internet for Outpatient Clinical Documentation Improvement Program. Provide a brief overview. (Hint: You will be asked to research for discussion posting)

7. Search the Internet to determine the steps Managed Care organization are doing to prevent fraud and abuse among patients and health care providers. Address each party (patients and providers). You must list and explain at least three fraud and abuse tactic.

8. Determine the role of managed care in the health information exchange (HIE). Search the Internet to enhance your knowledge. Briefly discuss your understanding of HIEs. (Do not copy and paste)

9. Access the “Insurance Ranking” website on the Managed Care Websites listed in the lesson. Submit grid below and required data with Study Guide questions. On the last line, you choose a health plan located in Florida and submit findings in the Discussion Forum (specify why you choose the health plan):

Rank Plan Name Type Score Consumer Satisfaction

Prevention Treatment

AvMed Health Plans HMO

Cigna HealthCare South FL HMO

Humana Medical Plan HMO

Your selection

10. Now that you have completed #9. Review the HEDIS Report Card for the patient listed below:

Your 73-year-old Uncle Henry lives in Pennsylvania and is looking for a Medicare PPO to join. It is open enrollment and he has asked for your help. Uncle Henry knows that you work as a Health Information Technician and you have knowledge about health plans. He has several chronic diseases including diabetes, hypertension, and Parkinson’s disease. In particular, he wants to join a PPO that is highly rated for helping individuals live with their illnesses. Help Uncle Henry create a report card on the HEDIS website to evaluate the health plans. Search the website: https://www.ncqa.org/report-cards/health-plans/

Which health plan would be the best selection and why?

11. Case Study – Read case study below. Your goal will be to research on the Internet “Quality Management in health care”, understand the role of a Quality Manager in the healthcare arena. Make recommendations to resolve the issues.

12. Go to https://www.uhc.com/understanding-health-insurance/common-terms . Select “Terms to Know”. Review terms and watch video. Learn more about health insurance and their terms. Write a paragraph on this website contribution to lay persons understanding health insurance. Add a second paragraph on one or two terms you did not understand. Discuss how the terms will assist you in becoming more knowledgeable when referencing health insurance.

13. Post to Discussion area #1 your choice of the health plan selected in question #8. Go to the Health Plan Report Card (Hint-become familiar with accreditation status levels) add the HEDIS, CAHPS score and accreditation status. Offer classmates a paragraph why you choose the health plan with rational. Use the grid below (copy and paste) to share findings with

Case Study

You are the newly appointed director of quality management at a medium-sized MCO that was originally a group model but now have about half of its members cared for by physicians in a network model arrangement. NCQA has recently adopted and promulgated a new set of measures for quality of care of diabetics and you know that the results will be publicized, with customers encouraged to use them to choose plans. Much of the information needed is available in your administrative data a set, which includes frequency of visits, laboratory tests, etc. You note with both interest and concern that the performance of the network physicians is nowhere near as good as that of the large group practice that is the out-growth of your old staff model arrangements. You are also very aware that patients must be active partners if your plan is going to do well on these measures, since so many of the events are ones in which patients must choose to receive care.

1. What steps would you take to improve quality in this area? 2. Should you use financial incentives or other means with the

doctors? 3. What will you do with respect to patients known to be diabetic? 4. Is there any use you could make of the difference in baseline

performance between the two sets of doctors?

classmates:

Rank Plan Name

Type

Score Consumer Satisfaction

Prevention Treatment HEDIS CAHPS Accreditation

Your reason:

14. Post findings to the Discussion area #2. Provide information of your findings and respond to at least two of your peers. Go to http://floridahealthfinder.gov . Allow screen prompts to rotate. Access the screen prompt for Take the website tour. Then, select links to Compare prices of surgery and medications. For the surgery, list the common disease and its etiology for which the surgery is performed. For the medication, offer the common disease the drug is prescribed.

15. Post findings to the Discussion area #3. Picture yourself as working in a physician’s group practice. The physicians in the practice have tossed around the idea of signing up for the Outpatient Clinical Documentation Improvement Program offered through Medicare and Commercial Insurance carriers. Research the Outpatient CDI topic, the responsibilities of the office physician(s) and office staff. Discuss how the program will affect the work of the physician, the staff, the quality of care of patients, and reimbursement. Address Outpatient CDI and all three aspects of questions. Your initial response must be 150 words or more. Respond to peers.

16. Complete Pre-test of Managed Care