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HSM 546 Week 4 Assignment Managed Care Enrollment
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HSM 546 Week 4 Assignment Managed Care Enrollment
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Scenario Summary Managed Care Plan Enrollment
Atlanta, Georgia has a very diverse work force, consisting of men and women of various ages, ethnic groups, skills, and education. Many people live and work in one of approximately 14 counties that make up the Atlanta region. It is not uncommon for an employee to drive close to 100 miles one way to get to work. The employer base is diverse as well, consisting of large and small employers that range from entrepreneurs; healthcare services; local, state, and federal government offices; information technology; higher education; landscaping; personal services; banking; and the fast-food industry. Now that we have some background information, let’s learn more about the ABC Insurance Company located in Atlanta.
The ABC Insurance Company has been very aggressive and quite successful in recruiting companies, organizations, and individuals to join its managed care plans. Their ranges of services and rates have been extremely competitive. Their employer base is spread out among the 14 counties, which has been attractive to many employers. The ABC Insurance Company has been quite successful in selling its managed care insurance program to employers and organizations, so what is the issue?
Verde Greene Hospital has an excellent reputation for quality in maternity care, cardiac rehabilitation, and orthopedic medicine, and it is the only hospital in town to have received the Magnet Award for Excellence in Nursing. A sizable number of employer groups as well as employees, who have insurance coverage with ABC Insurance Company, want Verde Greene Hospital to be included in the network as a participating hospital.
When ABC insurance company approached Verde Greene Hospital to recruit it as a participating provider in their managed care plan, Verde Greene Hospital was very delighted to be asked. In fact, the hospital’s overall response was quite positive. However, there was one contractual stipulation that Verde Greene Hospital needed prior to signing any contracts and becoming a participating provider. Specifically, Verde Greene wanted to be the exclusive provider of maternity and cardiac care for all the patients in the ABC Insurance Company network: no exclusivity, no deal.
Because so many employers had pressured ABC Insurance Company to contract with Verde Greene Hospital, the insurance company agreed to the stipulations and agreed to enroll Verde Greene as a participating provider of care and an exclusive provider of cardiac and maternity services. This contract is legally binding for both parties, and they are scheduled to sign this contract in 10 days.
It appears that the exclusivity clause in the contract may have created several unanticipated problems, which are listed below.
It means that patients who needs cardiac or maternity care may need to drive 50 miles and pass four or five other good hospitals in the plan network in order to get the care they need at Verde Greene Hospital. A number of obstetrics and gynecology physicians, as well as cardiologists, who reside in one of the 14 counties do not have privileges at Verde Greene Hospital and have threaten to disenroll from the plan if Verde Greene Hospital is the only hospital contracted to see their patients. Even if these physicians are given hospital privileges, this would mean more staff meetings and Emergency Department duty at a hospital that is too far away. The existing staff physicians at Verde Greene Hospital object to the loss of available hospital space and time, as well as to the possibility of losing existing patients to the new physicians. These physicians also threaten to disenroll from the plan. The other hospitals in the managed care plan object to the loss of patients and have threatened to disenroll from the plan as well and have threatened to sue for restraint of trade.
Your Assignment
What should ABC Insurance Company do? Why? How? What should Verde Greene Hospital do? Why? How? What should the employers do? Why? How? What should the patients do? Why? How?
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HSM 546 Week 3 Quiz
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HSM 546 Week 3 Quiz
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(TCO D) Capitation will solve the issue(s) of _____.
(TCO D) Which of the following is the leading reason for member complaints?
(TCO D) Discuss how information technology (IT) can make disease-management programs more successful.
(TCO D) Which of the following is not necessarily a red flag for case management?
(TCO D) Which of the following aspects of the claims capability must be counted or measured in order to allocate adequate resources and verify financial assumptions about an insured population?
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HSM 546 Week 3 DQ 2 Managed Care Underwriting
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HSM 546 Week 3 DQ 2 Managed Care Underwriting
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Discuss problems that MCOs have experienced when implementing capitation arrangements in specialty-care practices.
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HSM 546 Week 2 DQ 2 The Effect of Human Behavior
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HSM 546 Week 2 DQ 2 The Effect of Human Behavior
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Explain what actions on the part of the HMO organization would likely cause negative physician behavior. Please provide an example to support your position.
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HSM 546 Week 2 DQ 1 Utilization Management
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HSM 546 Week 2 DQ 1 Utilization Management
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Discuss the concept of managing utilization. Incorporate into your discussion the role of the provider and case management. Describe the differences in managing the utilization for acute-care patients versus chronic-care patients.
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HSM 546 Week 2 Assignment You Decide Cooper Pearson Sports Marketing
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HSM 546 Week 2 Assignment You Decide Cooper Pearson Sports Marketing
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Scenario Summary:Cooper-Pearson Sports Marketing
Cooper-Pearsonis a very successful sports-marketing company with 75 employees. It has been in existence for 10 years, and it clearly has a bright future. One of the fundamental reasons for Cooper-Pearson’s phenomenal growth has been an investment in selecting the best and brightest men and women from colleges and universities throughout the United States and paying them well. Cooper-Pearson Sports Marketing has noticed that, in the past 2 years, 15 key senior employees have left the firm. Many of these men and women have joined Always on the Ball Sports Marketing Company, a competitor of Cooper-Pearson. During the exit interviews, one of the reasons that was consistently mentioned as a reason for leaving was the lack of adequate or affordable medical insurance.
Cooper-Pearson Sports Marketing managers have come to understand that a competitive compensation package must include medical benefits that employees want and can afford. They also understand that medical insurance has become an important recruitment tool in attracting quality employees. Like the company, quality coverage is extremely important, but so is cost.
Your Role
The company has engaged your services to research several insurance programs. First, compare and contrast the differences between an HMO, a PPO, and an indemnity insurance program. From the list below, select and discuss at least one other important service that Cooper-Pearson should consider when selecting an insurance program.
- Discuss the importance of managed-care physician credentialing.
- Explain the benefits of a prescription drug program to the employer and the employee.
- Explain the importance of quality-management indicators in managed-care programs.
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HSM 546 Week 1 Quiz
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HSM 546 Week 1 Quiz
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(TCO B) The integral components of managed care are _____.
(TCO A) Which organization(s) need a corporate compliance officer (CCO)?
(TCO A) Basic elements of credentialing include _____.
(TCO B) When selecting a hospital during the network-development phase, an MCO considers the _____.
(TCO B) Common areas of clinical focus subject to hospital P4P programs include _____.
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HSM 546 Week 1 DQ 2 Managed Care Plans
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HSM 546 Week 1 DQ 2 Managed Care Plans
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What are PPO and POS plans? How do HMO plans differ from PPO plans?
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HSM 546 Week 1 DQ 1 HMO Formation
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HSM 546 Week 1 DQ 1 HMO Formation
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Why were HMOs formed? How has the relationship between the government and HMOs changed over the past 7 years?
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HSM 546 Entire Course
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HSM 546 Entire Course
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HSM 546 Week 1 DQ 1 HMO Formation
HSM 546 Week 1 DQ 2 Managed-Care Plans
HSM 546 Week 1 Quiz
HSM 546 Week 2 DQ 1 Utilization Management
HSM 546 Week 2 DQ 2 The Effect of Human Behavior
HSM 546 Week 2 HSM 546 You Decide Cooper-Pearson Sports Marketing
HSM 546 Week 3 DQ 1 Payment Mechanisms
HSM 546 Week 3 DQ 2 Managed-Care Underwriting
HSM 546 Week 3 Quiz
HSM 546 Week 4 DQ 1 Consumer Strategy
HSM 546 Week 4 DQ 2 Claims and Benefit Administration
HSM 546 Week 4 Managed Care Enrollment
HSM 546 Week 5 DQ 1 Social Insurance Medicaid
HSM 546 Week 5 DQ 2 Social Insurance Medicare
HSM 546 Week 5 Quiz
HSM 546 Week 6 DQ 1 The Regulatory Environment and Quality in Managed Care
HSM 546 Week 6 DQ 2 The Quality of Healthcare
HSM 546 Week 6 Executive Summary Article Review
HSM 546 Week 7 DQ 1 Issues Driving Federal Policy
HSM 546 Week 7 DQ 2 The Impact of Technology
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