Identify and discuss three basic ways to ensure the accuracy of claims processing within managed care.

Part 1
1. I am interested in your ideas on how managed care organizations can more effectively prevent diseases or more specifically preventing the spread of disease among its contracted population. In other words, what can HMOs do to promote health and reduce illness rather than treating it after the fact. Address cost implications, patient receptivity, provider cooperation and other factors impacting this issue.
2. One of the cornerstones of Accountable Care Organizations is the use of Evidence-Based Medicine. What is this, what are the negatives of EBM, and how can HMOs encourage the positive benefits of EBM.
3. The Health Care Industry has espoused “quality management” for decades. Please identify and briefly discuss three quality management processes, at whatever level you wish (insurance companies, hospitals, medical groups, nursing homes, etc.).
Part 2
1. Years ago it was quite common for HMOs to offer a wide range of behavioral health services, including in-patient hospitalization. More recently, HMOs have limited in-patient programs and encouraged out-patient services. Discuss some of the reasons for this shift.
2. One of the benefits to patients joining an HMO is the relatively strict peer-review and physician credentialing process required for accreditation. Discuss why the credentialing process is important and how it relates to quality management.
3. Discuss how managed care organizations design, market and sell their products to consumers, including individuals and companies.
4. Years ago when I worked for an HMO is Arizona, we contracted with a private company to provide our HMO with hospital discharge and cost data by physician specialty. We used this data to contract with the more cost effective physicians in the State. In effect, we were “provider profiling”. What are some of the potential negatives with using this type of data in the provider contracting process?
Part 3
1. In an attempt to improve quality in managed care, a report called HEDIS was established and expanded upon over the years. What is HEDIS and what is its proported value to health care?
2. One of the most important documents established between a contracted medical group and an HMO is a DOFR (Division of Financial Responsibility). Discuss the DOFR and identify three reasons why this document is important.
3. The American Recovery and Reinvestment Act of 2009 included a provision to establish the HITECH Act (Health Information Technology for Economic and Clinical Health Act). Identify and discuss three provisions of this Act.
4. Identify and discuss three basic ways to ensure the accuracy of claims processing within managed care.
Part 4
1. ACA requires HMOs to achieve a certain “medical loss ratio”. What is a “medical loss ratio” and why is this an important issue?
2. After the passage of Medicare, the federal government has played a major role in setting health policy. Identify and briefly discuss three federal laws regulating health care which have had a material impact on HMOs and the health care industry in general.
3. Over a dozen years ago, California established the Department of Managed Health Care, one of the first in the nation to recognize that HMOs were different from other forms of health care insurance. Please identify and discuss three major functions of this Department.
4. Incurred But Not Reported (IBNR) in claims processing can (and has) led to insolvency on the part of some medical group. Discuss IBNR and identify several ways capitated medical groups try to address this issue.
5. There are two basic methods HMOs (and other insurance companies) use to rate the risk of providing insurance to employers: experience rating and community rating. Briefly discuss each method and explain the merits and problems associated with each method.

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