Managed Care All Discussions and Midterm Exam

Part 1-

DQ1: SQL is the standard language for relational database management systems. Although all vendors comply with the ANSI (American National Standards Institute) standard for SQL, is there much dissimilarity in the way they implement the standard? What are the ramifications of these dissimilarities? Do you feel that one vendor's product is better than others because of this?

DQ2: One of the advantages of using SQL is the ability to drill down into the data using functions to generate useful information for our users. What are some of the more common SQL functions, and how would you use them to generate useful information for your organization? 

Part 2-

DQ1: Why do managed care organizations seek to establish a provider network? What are the primary reasons for contracting with providers?

DQ2: Describe and discuss the key issues associated with provider payment that should be addressed in any managed care contract.

Part 3-

DQ1: What are the primary categories of utilization management (UM)? How does UM determine medical necessity through the use of evidence-based guidelines?

DQ2: What are the key differences between conventional case management and disease management? Provide some examples of diseases that seem to benefit from a disease management model of care. 

Part 4-

DQ1: What are the most important elements of a managed care pharmacy benefit program? And how are patient prescription benefits typically different under managed care?

DQ2: What factors surrounding behavioral health create special challenges and special considerations for managed care programs? How is managed behavioral healthcare different from managed acute medical or managed acute surgical care?

Part 5-

DQ1: Discuss the main elements of the managed care accreditation process. For each main element, explain why it is important.

DQ2: Discuss how managed care sales and marketing have evolved over recent decades, and how these may possibly evolve over the decades ahead.

 Part 6-

DQ1: Discuss fraud and abuse in healthcare. Provide at least three specific examples of fraudulent practices that have taken place in U.S. healthcare, and describe ways to prevent these in our modern healthcare environment.

DQ2: Explain the difference between underwriting and rating. What are the key elements that typically go into rate development formulas?

Part 7-

DQ1: What are the most critical components of state regulation for managed care organizations? And which federal regulations also bring specific requirements for the operation of such entities? Discuss state and federal regulation of MCOs.

DQ2: Compare and contrast the differences between pivot table reports in Excel and matrix reports in SQL Server. Are there any limitations in using matrix reports over Excel's pivot table? What are the advantages of using these reports, compared to standard table reports?

Midterm Exam-

1. Why were the first proto-HMOs formed in America? What were the original driving factors in the HMO movement?

2. What is meant by indemnity coverage, and how does it change in managed indemnity?

3. What is the role of the executive director in a managed care organization? Could you see yourself practicing in this position at some point in your career? Why or why not?

4. What is the role of the Peer Review Committee in a managed care organization? And why is this function so crucial?

5. Describe the calculation of capitated payments. How are these rates determined in managed care organizations?

6. Describe the use of evidence-based clinical criteria in managed care. Why is this process so important in managed care today?

7. What is meant by pattern review under managed care? Why do payers conduct pattern review, and what kinds of things might they identify during such reviews?

8. Discuss some key general aspects of physician practice behavior? Include implicit messages from training, and also environmental factors, in your answer.

9. What is the purpose of hold-harmless and balance-billing clauses in managed care contracts?

10. What is typically covered under "term, suspension, and termination" of a managed care contract?