Description
[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. Overview: 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) 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) 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) • 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) 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) 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) Review the attached grading rubric before submitting your assignment. Make sure you addressed each part of the project and the associated tasks. |