MH684 Managed Health Care


[11] Capstone Project

Capstone Project

MH684 Managed Health Care

(300 points total)

You should begin working on the capstone project early in the course. Each assignment provides a benchmark for completing this capstone in a timely manner while you work through each course lesson.


You’ll be required to submit a 12-16-page report which answers the prompts for each lesson. In your report, make it clear which prompt your response pertains to. For example, separate your responses from the prompts in lesson one from your responses to the prompts in lesson two by adding a new heading. Be sure to specify the narrative that applies to each prompt within each lesson by preceding your response with the letter associated with each prompt. For example, your responses between the prompts for “A” and “B” in lesson one should be made easily discernible.

Lesson 1: Health Insurance and Managed Healthcare: Its Origins and Developments – (2 Pages / 30 Points)

A. Describe some reasons why hospitals, health systems, and health plans are increasingly employing physicians directly. (10 Points)
B. Describe an ACO and the Medicare Shared Savings Program, and how these can result in improved patient outcomes while also reducing costs. (10 Points)
C. Other than establish the creation of ACOs, identify and describe five provisions of the Affordable Care Act and their impact on the healthcare industry. (10 Points)

Lesson 2: Health Plans, Payers, Provider Networks, and Health Benefits Coverage – (2-3 Pages / 70 Points)

Describe the differences between an open-panel and closed-panel HMO. (10 Points)
Describe what essential health benefits are and why they may vary between states. (10 Points)
Identify and describe three different ways payer organizations are structured. (10 Points)
Identify and describe five elements of a typical payer-provider contract. Discuss some reasons why payers and providers would want to contract with each other. (20 Points)
Describe why provider credentialing is important, who’s responsible for credentialing providers, the documentation used in provider credentialing, and how credentials are verified. (20 Points)

Lesson 3: Provider Payment (2-3 Pages / 50 Points)

A. Identify and describe the standardized code sets mandated by HIPAA, as well as commonly used code sets that aren’t mandated. Explain why these code sets are important. (10 Points)
B. Describe what fee schedules and maximum allowable charges are. Explain what Relative Value Units are and how these are used to determine reimbursement. (10 Points)
C. In an effort to enhance price transparency, Centers for Medicare and Medicaid Services (CMS) finalized policies in late 2019 that require hospitals to establish, update, and publicize a list of their standard charges for the items and services they provide. This includes:

  • Gross charge of an item or service that’s reflected on a hospital’s chargemaster
    • Discounted cash price for individuals who pay with cash or a cash equivalent
    • Payer-specific negotiated charge for all third-party payers for an item or service
    • De-identified minimum negotiated charge, or the least expensive negotiated rate with a third-party payer for an item or service
    • De-identified maximum negotiated charge, or the most expensive negotiated rate with a third-party payer for an item or service
  • Explain why some stakeholders fear that this final rule could lead to price fixing. (10 Points)

    D. Describe the possible benefits and challenges that a provider or health system may have when engaging in a capitated contract with a health plan. (20 Points)

    Lesson 4: Utilization Management, Quality Management, and Case Management (2 Pages / 40 Points)

    A. Describe different ways that utilization can be measured or projected for outpatient and inpatient services and how these can be used to determine payment rates set between payers and providers. (15 Points)
    B. Describe some reasons why it can be difficult to determine which drugs a health plan covers, and how this informs the creation of a formulary. Also describe the difference between an open and closed formulary. (10 Points)
    C. Describe the three interrelated categories of quality management activities. (15 Points)

    Lesson 5: Sales, Governance, and Administration of Payer Organizations (2-3 Pages / 50 Points)

    A. Describe the differences in responsibility held by the board compared to the management or leadership team of a health plan. (10 Points)
    B. Identify and describe four different mediums through which commercial health plans can sell their products. (10 Points)
    C. Describe the three categories of eligibility for coverage in the commercial market. (10 Points)
    D. Describe the process by which claims are processed and benefits are administered. (10 Points)
    E. Describe some ways in which fraud and abuse can occur, and how these activities can be detected. (10 Points)

    Lesson 6: Medicare and Medicaid; Health Insurance Laws and Regulations (2-3 Pages / 60 Points)

    A. Describe the five major components that determine the payment rates of Medicare Advantage plans. (15 Points)
    B. Describe the different responsibilities in the regulatory oversight of Medicare Advantage plans from the federal, state, and corporate level. (10 Points)
    C. Describe how the payment rates of Medicaid managed care plans are determined. (10 Points)
    D. Identify and describe four ways that states oversee and regulate managed care organizations. (10 Points)
    E. Describe the federal government’s role in in overseeing and regulating managed care organizations, and why this presents challenges when federal laws conflict with state laws. (15 Points)

    Review the attached grading rubric before submitting your assignment. Make sure you addressed each part of the project and the associated tasks.

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    Living Guideline

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    NCBI Bookshelf

    Rodriguez Ziccardi, M., Goyal, G., & Maani, C. V. (2020, August 10). Atrial flutter. In Statpearls. StatPearls Publishing.

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