Course Information

Course Title:

Health Insurance and Managed Care

Course Number:

HSM546

Course Description:

Health Insurance and Managed Care examines the evolution of and the development of ?managed care approaches to the delivery and financing of health services in the United States. The history of health insurance and managed care will be reviewed in the course. Managed care organizations, network contracting, and provider payments will be analyzed along with the fundamental concepts of management of utilization and quality, the core competencies of disease management, provider profiling in healthcare plans, and prescription benefits. Types of service delivery systems and accreditation and performance measurement programs in managed healthcare will be reviewed in the course. We will examine special markets including Medicare advantage plans, Medicaid, and military health systems. The laws and regulations that govern health insurance will include federal and state regulations that are required for health insurers and managed care plans.

Course Prerequisites:

N/A

Course Specific Requirements

Each class will have assigned topics and accompanying reading assignments. Class material will supplement and build on the reading assignments, so it is important that you come to each class prepared with the reading assignment completed. Selected homework assignments designed to augment your understanding of course content will also be assigned. Timely completion of assignments is expected.

Relating course content to your own and others’ work environments is an integral part of learning, as well as developing a strong awareness of how healthcare is changing in the current marketplace. To that end, students are encouraged to relate course content to current work situations and to bring to class relevant materials from the media that enhance understanding and application of course concepts. Active class participation that reflects learning from the assigned readings, homework assignments, and classroom discussion is expected.

Written Assignments

In this course, you are expected to demonstrate writing proficiency. Pay careful attention to paragraphing, sentence structure, quotation conventions, spelling, punctuation, citation protocol, and other aspects of grammar. Remember to proofread, correcting any typing or printing errors. APA citations and references are required for all assignments, including discussion questions, and the Publication Manual of the American Psychological Association (sixth edition) is the overarching guide for APA style and form.

All papers written for this course should follow the standards that are applicable in the business environment. This includes a business-appropriate writing style and no misspelled words or grammatical errors. Presentation and organization, although not as important as content, will impact your grade. Always write as if the reader is unfamiliar with the material you are presenting.

It is important that you learn to catch mechanical errors in your writing. Research has shown that they can make a bad impression. In 2001, Larry Beason published a study of how businesspersons react to minor writing errors. He found that "For some readers, simple accidents or certain errors have little impact, while other readers see the same errors and create a damning portrait of the writer." Many of the business persons in his study interpreted mechanical errors as evidence that the writer was a poor businessperson—a faulty thinker, not a detail person, a poor oral communicator, and/or a poorly educated person. Some also interpreted mechanical errors as evidence that the writer was hasty, careless, uncaring, and/or uninformed.

(Beason, L. (2001). Ethos and error: How business people react to errors. College Composition and Communication, 53(1), 33–64.)

Consider this finding from the National Commission on Writing, which surveyed 120 American corporations and 50 state government institutions (College Board, 2004): The ability to write well "is now a core competence requirement for advancement," and "workers who cannot write and communicate clearly will not be hired and are unlikely to last long enough to be considered for promotion." Although two thirds of workers are expected to write business e-mails, proposals, and other correspondence, only one-third are able to do so in "clear, logical prose."

(College Board. (2004). Report from the national commission on writing. Retrieved from http://www.collegeboard.com/prod_downloads/writingcom/writing-ticket-to-work.pdf)

The following grading template will be used for written assignments for Weeks 2, 3, 5, and 6. There are 50 points possible on each assignment.

CriteriaDistinguishedProficientBasicBelow ExpectationsNon PerformancePoints
Content/Subject KnowledgeThoughtful analysis;  Valuable insightThoughtful analysis; lacks depthIncomplete analysis of topicWeak and lacks analysis of discussion topicNonexistent or no original thoughts 
40%20 points15 points12 points10 points0 points20
Coherence/OrganizationCommunicates idea entirelyCommunicates idea in a coherent mannerCommunicates main ideaIdeas and thoughts unconnectedNonexistent or lacks ideas 
30%15 points12 points10 points8 points0 points15
MechanicsFew grammar, spelling, and APA errorsMinor grammar, spelling, and APA errorsGrammar, spelling, and APA errorsMajor grammar, spelling, and APA errorsExtensive APA, grammar, and spelling errors 
30%15 points12 points10 points8 points0 points15
 Total Weekly Points                   
Read Comments  

Software Citation Requirements

This course uses open-source software, and as the end users of this software, students are required to cite the software for any student work, such as assignments, labs, or projects, where the software has been utilized. Open-source software does have end-user license agreements, and all students should read the entire agreement for a software prior to installation or usage. In order to use the software in this course, software citations have been created for students and can be located on the Open Source Applications page. These software citations must be included in all student work submissions that have used the software.

Textbooks and Resources

Required Textbooks

The following books are required for this course:

Essentials of Managed Health Care

6th Edition

by Peter R. Kongstvedt


Companion Website Online Access Code


E-book Details

First Time Using VitalSource?

Step 1: View the VitalSource Video

Step 2: Register with VitalSource Bookshelf Online

  1. Select the "eBooks" tab at the top of the window.
  2. Select the cover of your eBook.  A new window will open.
  3. Check the box next to "Accept license agreement" and click "Continue."  Bookshelf Online will open.

Step 3: Access the Desktop and Mobile Versions
You must complete Step 2 prior to using the desktop or mobile versions.

Already Registered?  3 Ways to Access Your eBooks

Online

  1. Select the "eBooks" tab at the top of the window.
  2. Select your eBook.  Bookshelf Online will open.

Desktop

Download your eBooks and use them whether you're connected to the Internet or not.

 

Mobile

Download the app and get your eBooks on your iPhone, iPad, or Android device.

 

To find out more about VitalSource Bookshelf, check out the VitalSource FAQ.

Campus Additional Information

Enter content here, if necessary.

Terminal Course Objectives

DeVry University course content is constructed from curriculum guides developed for each course that are in alignment with specific Terminal Course Objectives. The Terminal Course Objectives (TCOs) define the learning objectives that the student will be required to comprehend and demonstrate by course completion. The TCOs that will be covered in detail each week can be found in the Objectives section for that particular week. Whenever possible, a reference will be made from a particular assignment or discussion back to the TCO that it emphasizes.

A

Given the fundamental characteristics of managed care, identify current trends in managed healthcare and the present conditions in the managed care health environment.

B

Evaluate the major types of health insurers and managed healthcare organizations and define integrated delivery systems, including the strengths and weaknesses of each type of system.

C

Given the development of the Patient Protection and Affordability Act, evaluate governance requirements, risk management, and provider networks.

D

Analyze and contrast the general principles of the different methods of provider payment, and compare the basic approaches to hospital-and physician-focused pay for performance.

E

Articulate a scenario involving a managed care organization or integrated delivery system, and develop a plan to proactively address legal issues in provider contracting.Objective

F

Compare and contrast basic utilization management techniques and the challenges associated with managing utilization.

G

Evaluate the types of healthcare marketplace health plans and compare different healthcare plans.

H

Given the federal regulations for health insurance and managed care, craft a healthcare policy to address the Health Insurance Portability and Accountability Act (HIPAA) that meets federal requirements.

Lab Schedule

Week 1

None
Citrix
RKON
Skillsoft
Toolwire
WebServer
ACC COMAT
ACC NonCOMAT
CWP

Week 2

None
Citrix
RKON
Skillsoft
Toolwire
WebServer
ACC COMAT
ACC NonCOMAT
CWP

Week 3

None
Citrix
RKON
Skillsoft
Toolwire
WebServer
ACC COMAT
ACC NonCOMAT
CWP

Week 4

None
Citrix
RKON
Skillsoft
Toolwire
WebServer
ACC COMAT
ACC NonCOMAT
CWP

Week 5

None
Citrix
RKON
Skillsoft
Toolwire
WebServer
ACC COMAT
ACC NonCOMAT
CWP

Week 6

None
Citrix
RKON
Skillsoft
Toolwire
WebServer
ACC COMAT
ACC NonCOMAT
CWP

Week 7

None
Citrix
RKON
Skillsoft
Toolwire
WebServer
ACC COMAT
ACC NonCOMAT
CWP

Week 8

None
Citrix
RKON
Skillsoft
Toolwire
WebServer
ACC COMAT
ACC NonCOMAT
CWP

Course Schedule

Week, TCOs, and TopicsReadings and Class PreparationActivities and Assignments
Week 1

TCO A

Introduction to Managed Care and Current Trends

Chapter 1: A History of Managed Health Care and Health Insurance in the United States

Chapter 12: Introduction to Managed Behavioral Health Care Organizations

  1. Graded discussion topics
    • Managed Care and Current Trends (graded)
    • Quality and Access (graded)
Week 2

TCO B

Managed Care Organizations and Integrated Delivery Systems

Chapter 2: Types of Health Insurers, Managed Health Care Organizations, and Integrated Health Care Delivery Systems

Chapter 3: Elements of the Management and Governance Structure

Chapter 12: Introduction to Managed Behavioral Health Care Organizations

  1. You Decide activity
  2. Graded discussion topics
    • Types of Health Insurers (graded)
    • Governance of Managed Care Organizations (graded)
Week 3

TCO C

Patient Protection and Affordable Care Act, Risk Management, and Provider Networks

Chapter 4: The Provider Network

Chapter 9: Physician Practice Behavior and Managed Health Care

Chapter 29: Federal Regulation of Health Insurance and Managed Care

Chapter 30: The Patient Protection and Affordability Act

  1. Written assignment
  2. Graded discussion topics
    • Provider Networks (graded)
    • Federal Regulations (graded)
Week 4

TCO D

Provider Payment and Payment Methods

Chapter 5: Provider Payment

Chapter 9: Physician Practice Behavior and Managed Care

Chapter 18: Claims and Benefits Administration

  1. Midterm
  2. Graded discussion topics
    • Provider Payment (graded)
    • Claims and Benefits (graded)
Week 5

TCO E

Legal Issues

Chapter 6: Legal Issues in Provider Contracting

Chapter 19: Health Care Fraud and Abuse

Chapter 28: State Regulations and Managed Healthcare

Chapter 29: Federal Regulation of Health Insurance and Managed Health Care

Chapter 30: The Patient Protection and Affordability Act

  1. Written assignment
  2. Graded discussion topics
    • Legal Issues (graded)
    • Fraud and Abuse (graded)
Week 6

TCOs F and G

Utilization Management and Healthcare Markets

Chapter 7: Basic Utilization and Case Management

Chapter 11: Prescription Drug Benefits in Managed Care

Chapter 24: Health Plans and Medicare

Chapter 25: Medicaid Managed Health Care

Chapter 26: The Military Managed Care Health System

  1. You Decide activity
  2. Graded discussion topics
    • Utilization Review (graded)
    • Medicare Advantage Plans and Medicaid Plans (graded)
Week 7

TCO H

Federal and State Regulations

Chapter 28: State Regulations and Managed Healthcare

Chapter 29: Federal Regulation of Health Insurance and Managed Health Care

  1. Course Project
  2. Graded discussion topics
    • State Regulations of Managed Care Plans (graded)
    • Federal Regulations of Managed Care Plans (graded)
Week 8
All TCOs
Final Exam

Blended E-Learning

This course is an 8-week, intensive course that includes both classroom-based and e-learning activities. Your participation in both areas is essential to your success in this course. You should expect to spend time each week participating in the prescribed activities both before and after our class meeting.

Participation before, during, and after class meetings is critical to your success in this intensive environment.

To get the most out of our weekly class meetings, it is essential that you come to class prepared. The weekly readings listed in the Course Schedule will prepare you for class. Our class meetings, in turn, will prepare you for upcoming exams and assignments.

Through the DeVry e-learning platform, you will be able to

  • review the Syllabus and weekly assignment information;
  • submit completed work for grading;
  • take quizzes and exams;
  • obtain copies of class handouts and notes;
  • e-mail the instructor and other students; and
  • participate in online discussion of class material.

iConnect Live

This course contains iConnect Live sessions that provide students with the opportunity to attend live presentations, which cover course materials, projects, and assignments. Please see the iConnect Live items for the days and times of the live sessions and for the link to enter each session. You will also receive e-mail reminders each week.

If you are unable to attend the live session, you can watch the recorded session by clicking on the Recordings link that will appear in the iConnect Live item after the lecture has concluded. Please contact your instructor with any questions.

Please note that because of unavoidable technological issues and presenter availability, the live lectures may be substituted with prerecorded lectures.

Due Dates for Assignments & Exams

Unless otherwise specified, the following applies.

  • Access to most weeks begins on Sunday at 12:01 a.m. mountain time (MT).
  • All assignments are to be submitted on or before Sunday at the end of the specified week that they are due, by 11:59 p.m. (MT).
  • All quizzes and exams are to be completed on or before Sunday at the end of the specified week that they open, by 11:59 p.m. (MT).

Note: Week 8 opens at 12:01 a.m. (MT) on the ending Sunday of Week 7. Any assignments or exams must be completed by 11:59 p.m. (MT) Saturday of the eighth week.

Due Dates for Assignments & Exams

All assignments, quizzes, and exams are to be completed per the schedule indicated by your instructor.

Assignment Values and Letter Grades

The maximum score in this class is 1,000 points. The categories, which contribute to your final grade, are weighted as follows.

Assignment Points Weighting
Discussions (40 points, Weeks 1–7) 280 28%
Written Assignments (50 points, Weeks 3 and 5) 100 10%
You Decide (50 points, Weeks 2 and 6) 100 10%
Midterm 120 12%
Course Project 200 20%
Final Exam 200 20%
Total Points 1,000 100%

All of your course requirements are graded using points. At the end of the course, the points are converted to a letter grade using the scale in the table below.

Letter GradePointsPercentage
A  930–1,00093% to 100%
A- 900–92990% to 92.9%
B+870–89987% to 89.9%
B  830–86983% to 86.9%
B- 800–82980% to 82.9%
C+770–79977% to 79.9%
C  730–76973% to 76.9%
C- 700–72970% to 72.9%
D+670–69967% to 69.9%
D  630–66963% to 66.9%
D- 600–62960% to 62.9%
F  599 and belowBelow 60%

DeVry Graduate Academic Policy and Relevant Resources

DeVry Undergraduate Academic Policy and Relevant Resources

Frequently Asked Questions

When are grades calculated, and how can I view my grades?

  • You must complete any quizzes and post your written assignments (if necessary) to the weekly Dropbox by Sunday 11:59 p.m. (MT) each week, except Week 8 which closes at 11:59 p.m. (MT) Saturday.
  • Once your work is reviewed, you should see comments and total points for each assignment in the Gradebook. Instructors should have Discussion work graded by the following Tuesday and all other assignments by the following Friday.
  • You may check your progress at any time by going to the Gradebook, selecting the week and then your name.
  • Click on the points earned for each assignment in the Gradebook to see any instructor comments.

What should I do if a discrepancy is found with my grade?

  1. Double-check the error and try to determine what caused it.
  2. Send your instructor an email explaining your findings.
  3. Trust that any error in grading will be corrected quickly

What if I cannot get my work submitted on time?

  • If you have an emergency that will cause your work to be late, please contact your instructor in advance of the due date so that arrangements can be made. Your instructor may reserve the right to deduct points for work turned in late based on the reason and the timeliness of notice.
  • If a technical problem prevents you from meeting the scheduled due date, please contact the Help Desk at 1-800-594-2402 and immediately email your instructor about the situation.

How can I get extra credit?

Extra credit is not an option.

Questions and Concerns

Please feel free to contact me for help with coursework or other areas that may impact your progress. Here are some examples.

  • Do you have general questions about attendance, deadlines regarding your courses, student financial aid, or other areas? 
  • Are you a member of the military service? Do you need to adjust your schedule due to active duty, or do you have questions about your GI Bill® benefits or have other unforeseen military and veteran-related issues that have developed?
  • Do you need supplementary student assistance? Please let me know if you are having academic difficulty and would like an ADA accommodation. Although I can talk with you about getting assistance, an excellent point of contact is the Office of Student Disability Services. You can reach the Office by calling 877-496-9050, option 3, or by e-mailing adaofficer@devry.edu or adaofficer@keller.edu.

Regardless of your situation, please feel free to contact me for assistance in whatever area of concern you might have. I will do everything I can to assist you or put you in contact with University colleagues who are trained to assist you in whatever area of concern you might have.

"GI Bill® is a registered trademark of the U.S. Department of Veterans Affairs (VA). More information about education benefits offered by the VA is available at the official U.S. government website: www.benefits.va.gov/gibill.”

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