HC463 Third Party Reimburse & Risk Mgt

for U1T 2007

Printer Friendly

Mission Statement: The mission of Park University, an entrepreneurial institution of learning, is to provide access to academic excellence, which will prepare learners to think critically, communicate effectively and engage in lifelong learning while serving a global community.

Vision Statement: Park University will be a renowned international leader in providing innovative educational opportunities for learners within the global society.


HC 463 Third Party Reimbursement and Risk Management


U1T 2007 DL


William N. Goodwin


Senior Instructor


BBA-Accounting Texas A&M University-Kingsville
MBA-Texas A&M University- Corpus Christi

Office Location

Park Campus Center-Corpus Christi-NAS

Office Hours


Daytime Phone


Other Phone



William.Goodwin @Pirate.Park.Edu


Semester Dates


Class Days

Online Class

Class Time




Credit Hours



Image of Item
Principles of Risk Management and Insurance
Required Edition: 10TH 07 Rejda, George E.

Textbooks can be purchased through the MBS bookstore

Textbooks can be purchased through the Parkville Bookstore

Additional Resources:


McAfee Memorial Library - Online information, links, electronic databases and the Online catalog. Contact the library for further assistance via email or at 800-270-4347.
Career Counseling - The Career Development Center (CDC) provides services for all stages of career development.  The mission of the CDC is to provide the career planning tools to ensure a lifetime of career success.
Park Helpdesk - If you have forgotten your OPEN ID or Password, or need assistance with your PirateMail account, please email helpdesk@park.edu or call 800-927-3024
Resources for Current Students - A great place to look for all kinds of information http://www.park.edu/Current/.
Advising - Park University would like to assist you in achieving your educational goals. Please contact your Campus Center for advising or enrollment adjustment information.
Online Classroom Technical Support - For technical assistance with the Online classroom, email helpdesk@parkonline.org or call the helpdesk at 866-301-PARK (7275). To see the technical requirements for Online courses, please visit the http://parkonline.org website, and click on the "Technical Requirements" link, and click on "BROWSER Test" to see if your system is ready.
FAQ's for Online Students - You might find the answer to your questions here.

Course Description:
Public and private insurance, case management, preferred provider organizations, health maintenance organizations, and other forms of third party payment for health care services.  Loss prevention for the health care organization through risk management and cost containment.  3:0:3 

Educational Philosophy:

The facilitator’s educational philosophy is one of interactiveness based on lectures, readings, quizzes, dialogues, examinations, internet, videos, web sites and writings. The facilitator will engage each learner in what is referred to as disputatious learning to encourage the lively exploration of ideas, issues and contradictions.

Learning Outcomes:
  Core Learning Outcomes

  1. Describe the various forms of third party payment mechanisms for health care services.
  2. Define the various types of risk exposure that health care providers are confronted with in today's real world environment.
  3. Differentiate between the various third party payers and identify the most important aspects of each different payer's payment process.
  4. Formulate basic corrective or preventive measures for the various types of risk exposure health care providers must deal with on a day-to-day basis.
  5. Evaluate the loss prevention measures utilized by health care providers.
  6. Select the most appropriate payment methodology for a health care institution's services to ensure the maximum financial benefit to that institution.
  7. Determine the appropriate cost containment measures to be used by a health care provider.
  8. Recommend an appropriate operational response for the common compliance issues faced by health care providers in today's regulatory environment.

Core Assessment:

Class Assessment:

Weekly Activities

You will be able to track your average throughout the course. The grading scale is below. You will know in advance the standards for each assignment. My goal is to give you prompt, clear, and useful feedback to help you learn about risk management. Each student is responsible for:
    • Completing weekly quizzes consisting of true and false questions from the text             60 pts
    • Reading the weekly discussion article and posting to related discussion thread            150 pts
    • Answering the weekly homework questions and essays. (place in Drop Box)                220 pts
    • Taking the  Midterm Exam                                                                                       150 pts
    • Writing a summary paper on a current risk management article                                     50 pts
    • Completing a Research Paper on the Risk Management process.                                120 pts 
    • Completing the Final Exam                                                                                       250 pts

Other Assessment Guidelines

All work must contain appropriate formatting, grammar, and spelling.

Completing a student opinion survey form located in the Distance Learning section of the Park University website in Week Eight of this class.

Locating a suitable Proctor with e-mail and Completing a Proctored Final Examination.

The final exam will be closed book and closed notes.

Weekly Discussion Article Rubric


Discussion Participation Rubric - HC 463

After reading the assignment, write a reflection piece that includes:

  • A summary of 3 main points you gained from the reading (You may list the points, but elaborate and reveal your thoughts so we can understand them and respond.)
  • Your findings and any connections that you make (What seems particularly true or sensible to you as you read, and why you think so? How does this article connect to your prior knowledge or experience, other readings in this course, and the lecture content?)
  • Is there any point on which you disagree, and why? Write about what about the reading has left you confused or wondering or uncertain. What didn’t you understand? What questions does it raise in your mind?
  • Rating. On a scale of 1-5 (with 1 the most positive and 5 the least) how would you rate this reading in terms of its value to you in learning?

Key Element

90 - 100

80 - 89

70 - 79

Below 70


Quantity and timing of posts

First post by Wednesday. Posts 2-3 days/wk. Offers 2 original posts; responds to 2+ others

First post by Wednesday. Posts 2-3 days/wk. Offers 1 original post; responds to 2+ others

Initial post by Thursday. Typically participates 1-2x more during the week  

Does not participate, or posts Friday or later. Typically posts 1-2x in a week

Promptness and initiative

Consistently responds to postings in less than 24 hours; demonstrates initiative

Responds to most postings within a 24 hour period; requires occasional prompting to post

Responds to most postings several days after initial discussion; limited initiative

Usually responds to few postings; rarely participates freely (if at all)

Delivery of post

Consistently uses correct grammar and punctuation, with rare misspellings

Few grammatical or spelling errors are noted in posts

Errors in spelling and grammar are present in several posts

Uses poor spelling and grammar in most posts; posts appear hastily written

Relevance of posts

Consistently posts topics related to discussion topic; cites additional references related to topic

Frequently posts topics that are related to discussion content; prompts further discussion of topic

Occasionally posts off topic; most posts are short in length and offer no further insight into the topic

Posts topics that do not relate to the discussion content; makes short or irrelevant remarks

Expression within the post

Expresses opinions and ideas in a clear and concise manner with obvious connection to topic

Opinions and ideas are stately clearly with occasional lack of connection to topic

Minimal connection to topic, shown by minimal expression of opinions or ideas

Does not express opinions or ideas clearly; no connection to topic

Weekly Question and Essay Rubric 


                                           Homework Rubric

                                        Weekly Questions and Essays            

                           (Grade will reflect percentage of assigned points)

Key Element

90 – 100%

80 – 89%

70 – 79%

60 – 69%

Below 60%

Idea Development



Main point is present and directly supported.


Main point is present and most points supported.


Main point is present but vague; No direct support of main point.


Main point is vague with little support or strays from thesis.


Lacks organizing idea.




Well written, fully elaborates   points.


Well written, most points elaborated with clear and detailed information to support thesis; may contain minor factual errors.


Adequately written points; some points elaborated.


Awkward writing style, points are general, factual errors present, and may stray from main points. 


Poor writing style with little or no specific details.




Clearly organized.


Good 0rganization with few statements out of place.


Organization present but awkward.
May contain several statements out of place, problems existing with conclusion.


Organization is confusing to the reader. Organization lacks proper paragraph construction.


Little or no structure.

Rambles from topic to topic.  Completely off topic.



No errors interfering with comprehension.


Possesses 1-3 critical errors interfering with comprehension.


Possesses 4-5 critical errors interfering with comprehension.


Possesses 6-7 critical errors interfering with comprehension.


Possesses 7 or more errors interfering with comprehension.





Course Grading Scale 

  A = 900-1000 points

  B = 800-899   points

  C = 700-799   points

  D = 600-699   points

  F =      0-599   points



Quizzes                          60  points
Discussion                   150 points 
Research Paper          120 points
Weekly Homework     220 points
Article Summary           50 points
Midterm Exam            150 points
Final Exam                  250 points 
Total                           1000 points


All final exams will be comprehensive and will be closed book and closed notes.  If calculators are allowed, they will not be multifunctional electronic devices that include features such as: phones, cameras, instant messaging, pagers, and so forth.  Electronic Computers will not be allowed on final exams unless an exception is made by the Associate Dean.

The Proctored final exam for online courses must be passed with a grade of 60% or higher in order to pass the course regardless of the overall average.  The grade for students who pass the proctored final will be based on the overall average of homework and tests taken during the course.  The proctored final exam must address only material which the student has been taught in class.

Late Submission of Course Materials:
Late work will be evaluated on a case - by - case basis.

Classroom Rules of Conduct:

Ground Rules for Online Participation:
1. If you experience computer difficulties (need help downloading a browser or plug-in, you need help logging into the course, or if you experience any errors or problems while in your online course, please contact the Park Computer Center.
2. Back up: every piece of work you complete. This will ensure that a computer glitch, or a glitch out there in cyberspace won't erase your hard work.
3. Communicate: If you are experiencing any confusion over course material, technical difficulties that are not being resolved and are preventing you from completing your assignments, or general questions about the course, let me know and refer to Course Policy #1.
4. Please check the Announcements area in the Course Conference before you ask general course questions.  If you don't see your question there, then please post your question.  Posting them in the threaded discussion area will allow your fellow students to benefit from your questions.  And remember, there are no stupid/silly questions.  We are all here to learn!
5. E-Mail Procedures and Submitting General e-mail: When sending e-mail other than assignments, you must identify yourself fully by name and class in all e-mail sent to me and/or other members of our class.
My Response Policy: I will check my e-mail frequently. I will respond to course-related questions within 24-48 hours (unless I notify you previously that I will be unavailable).
6.  Late Work: Each week's work must be completed by the end of that week. No credit for work turned in after the week, unless you have contacted me beforehand and explained any "special" circumstance. Deadlines not met during the week will mean your grade will be lowered a half grade for each day late.
7.  Online Etiquette: All your online communications need to be composed with fairness, honesty and tact. Your online writings will be graded.  Here are a couple of online references that discuss writing online http://goto.intwg.com/ and netiquette http://www.albion.com/netiquette/corerules.html. If you have questions about any of these policies, please contact me for clarification.

8. This course is offered on-line, over the Internet, using the ECollege computer service. Each students is expected to devote a minimum of five hours per class week logged on to the computer conferencing system. This is same amount of time you'd spend in the physical classroom. See "Ground Rules for On-line Participation" for additional information.

9. According to Park University guidelines, this course is divided into eight weeks with the first week beginning on the first day of the semester, a Monday, and ends midnight the following Sunday. Weeks Two through Eight also begin on Monday and end on the following Sunday. Assignments scheduled for completion during a class week should be completed by the end of the week assigned, ie.,1,2,3-8. Writing assignments and formal papers should be completed and successfully emailed so that they are in by the due date.

10. Students are expected to complete 5 hours per week of conferencing or other appropriate online activities, including sending/receiving E-mail and navigating and conducting research over the World Wide Web.

11. Students will normally submit papers as MS Word, RTF or ASCII uploaded to the computer and routed to the instructor or emailed. Please do not use any MS Works format. Overall it works well to copy your assignments from you word processing program and paste it into the e-mail.
12. If you need help of any kind, please feel free to email or call me at the numbers included above with the syllabus.


Course Topic/Dates/Assignments:

Week 1 Introduction to Risk Management

Learning Objectives

1. What is the difference between risk and chance of risk?. Give examples of each.

2. Loss prevention activities can be divided into two categories: loss prevention and loss reduction. How do these activities differ? Provide an example of each.

3. Explain the concept of adverse selection. How does this concept tend to influence the processes followed by insurance companies ?

4. Define the law of large numbers and why it is important to private insurers.

5. Explain the concept of preloss objectives and postloss objectives. Please give examples of each.

6. Describe the role that technology plays in formulating risk management programs.

7. Describe the risk management process in detail. Be sure to explain the technique of risk control and risk financing.

8. Explain the methods that a risk manager employs to forecast possible losses. Give examples of each .
Study Chaptersrs 1-4 and read the posted lecture.

Participate in weekly discussion article thread.

Complete weekly assignments.

Complete weekly quiz.

Submit topic for Research Paper.

Week 2 Legal Principles In Risk and Insurance
Learning Objectives

1. Explain the law of agency and how it affects the actions of insurance agents.

2. What are the three general rules of agency that govern the actions of agents and their relationships with insured’s?

3. Define the concept of coinsurance and deductible as each relates to health insurance policies.

4. Why are other insurance provisions necessary in insurance contracts?

5. What are the three categories of torts?

6. What are the common defenses against negligence?

7. Explain in detail the fundamental legal principles that are reflected in insurance contracts. (Requires one page).

8. Discuss the required components of an insurance contract.

9. Please define the term Res Ipsa Loquitur, expounding on the background of this legal concept. Give examples with your answer.
Study Chapters 5-7 and read the posted lecture.
Participate in weekly discussion article thread.
Complete weekly assignments.

Complete weekly quiz.
Start your proctor process.

Week 3 Defining Risk Management and Liability Issues

Learning Objectives

1. Identify the major documents that form a commercial insurance package policy.

2. Describe the major coverages for insuring a business income loss. Give examples where appropriate.

3. Identify the major liability loss exposures of business firms.

4. What is errors and omissions insurance? Who should purchase this type of coverage?

5. Identify the insuring agreements in the commercial crime coverage form. Give an example of where each can be used.

6. What are the major differences between surety bonds and insurance?

7. Describe the major provisions of a commercial insurance umbrella policy.

8. How does claims-made insurance coverage differ from occurrence-based coverage? Explain how this difference can cost the health care provider substantial amounts in law suits.

9. What are the major types of surety bonds? Give examples of each.
Study Chapters 13-15 and read the posted lecture.
Participate in weekly discussion article thread.
Complete weekly assignments.
Complete weekly quiz.

Week 4
Different Health Care Plans

Learning Objectives
1. What are the two basic approaches for compensating physicians under surgical expense insurance?

2. Describe the difference between preexisting condition clauses concerning individual and group health insurance coverage.

3. Explain the basic rules to follow when purchasing individual health insurance.

4. Describe the advantages of long-term care insurance. How long has this type policy been available?

5. Explain what is meant by the term gatekeeper as it applies to health care policies.

6. Describe the advantages afforded an individual by disability insurance.

7. What are the major problems associated with the current health care system in the United States?

8. What are the typical characteristics of individual major medical insurance problems?

9. Please comment on your experience with individual health insurance, its cost, coverage, and any problems you have encountered in this area.

10. What is a health insurance renewal provision and why is the renewal provison important?
Study Chapter 21 and read the posted lecture.
Participate in weekly discussion article thread.
Complete weekly assignments.
Complete weekly quiz.
Complete Midterm Exam.

Week 5 Health Care Benefits and Risk Management

Learning Objectives
1. Define the term POS. Give examples of such plans.

2. Describe the basic characteristics of cafeteria plans.

3. Describe the ways insurance companies use the coordination of benefits provision in their payments to providers of health care.

4. Describe how self-insured health plans are operated. Do employers save money with these type of plans?

5. What is managed care? How do managed care plans differ from the traditional group health insurance?

6. What is a PPO? How do PPO's differ from EPO's? Give examples of each with your answer.

7. How are preexisting conditions provisions and coordination of benefits provisions often used in group health insurance plans?

8. What coverages are typically provided through group basic medical expense plans?

9. Discuss the basic underwriting principles used in group insurance.

Study Chapter 22 and read the posted lecture.
Participate in weekly discussion article thread.
Complete weekly assignments,
Complete weekly quiz.
Turn inresearch paper draft.

Week 6 Types of Insurance and Risk Management
Learning Objectives
1. Identify the major benefits offered under the Medicare Program.
2. What is Medigap insurance? Describe the development of such plans and the reasons they came about.

3. Describe the development of the Blue Cross and Blue Shield insurance plans. What percentage of the health care business do these plans represent today?

4. Explain the role of actuaries in the rate making strategy of insurance companies.

5. Discuss the concept of reinsurance and how it impacts the formulation of the health insurance packages offered by health insurance plans, HMO’s, PPO’s, etc.

6. What is a reinsurance pool? How and why would an insurance company use reinsurance?

7. Discuss the basic benefits offered under the Part B side of the Medicare program. How are these benefits paid for?

8. Discuss the recent passage of prescription drug coverage under the Medicare program. State and support your opinion of the new benefit for Medicare beneficiaries. Is the cost of this program prohibitive? ( 2 pages)

9. Discuss the role of underwriters in the insurance industry.

10. Discuss the concept of loss control and how it applies to the insurance industry.


Study Chapters 24-27 and read the posted lecture.
Participate in weekly discussion article thread.
Complete weekly assignments.
Complete weekly quiz.

Week 7
Current Risk Managment Topic

Article Summary

The summary should be about a current topic related to risk management. Article summaries and the orginal article should be submitted into the dropbox area for grading. Guidelines for completion of the article summary are as follows:

1. Locate a current article that examines a health issue topic that is relevant to the risk management process in health care delivery in the United States. (A website is not an acceptable resource, but journal articles found on the Internet are). Articles can be found at your local library, a college library, or from Internet sources. The article must show a correlation between the health care issues and risk management concepts discussed in your textbook. Textbooks are not an acceptable resource for this assignment.

2. Write a two-three page paper that includes the following components:

a. A summary of the article in your own words: DO NOT COPY from the article!

b. Your own personal reaction to the article: What did you learn? What did you think of the information provided?

c. Your analysis of how the article demonstrates a correlation between what we have been discussing in class (and in the text and lecture materials) about an issue.

In other words: What aspects of the article demonstrate how this particular policy issue impacts risk management in the following areas: hospital operations, health practices, financing of health care etc.

3. Submit the summary along with the copy of the article by the due date listed by Midnight on Sunday night of this week. Papers should be submitted to the drop box area.


Summary of Article
10 Points

Reaction to Article
10 Points

Analysis of Article: Correlation to Course
15 Points

05 Points

Source Material
05 Points

College Level Writing Skill
05 Points


Take weekly quiz

Turn in research paper final draft

Week 8 Risk Management Today

Please go back and read your past discussion articles for the first 6 weeks.
Your assignment is to put together a summation of what have learned from the various readings in the discussion threads and post it in the weekly discussion area.
Take your Final Exam.
Complete course evaluation.

Please type all content above this box.
Deleting this box or space below this box may break the Stylesheet

Academic Honesty:
Academic integrity is the foundation of the academic community. Because each student has the primary responsibility for being academically honest, students are advised to read and understand all sections of this policy relating to standards of conduct and academic life.   Park University 2006-2007 Undergraduate Catalog Page 87-89

Plagiarism involves the use of quotations without quotation marks, the use of quotations without indication of the source, the use of another's idea without acknowledging the source, the submission of a paper, laboratory report, project, or class assignment (any portion of such) prepared by another person, or incorrect paraphrasing. Park University 2006-2007 Undergraduate Catalog Page 87

Attendance Policy:
Instructors are required to maintain attendance records and to report absences via the online attendance reporting system.

  1. The instructor may excuse absences for valid reasons, but missed work must be made up within the semester/term of enrollment.
  2. Work missed through unexcused absences must also be made up within the semester/term of enrollment, but unexcused absences may carry further penalties.
  3. In the event of two consecutive weeks of unexcused absences in a semester/term of enrollment, the student will be administratively withdrawn, resulting in a grade of "W".
  4. A "Contract for Incomplete" will not be issued to a student who has unexcused or excessive absences recorded for a course.
  5. Students receiving Military Tuition Assistance or Veterans Administration educational benefits must not exceed three unexcused absences in the semester/term of enrollment. Excessive absences will be reported to the appropriate agency and may result in a monetary penalty to the student.
  6. Report of a "F" grade (attendance or academic) resulting from excessive absence for those students who are receiving financial assistance from agencies not mentioned in item 5 above will be reported to the appropriate agency.
ONLINE NOTE: An attendance report of "P" (present) will be recorded for students who have logged in to the Online classroom at least once during each week of the term. Recording of attendance is not equivalent to participation. Participation grades will be assigned by each instructor according to the criteria in the Grading Policy section of the syllabus.

Park University 2006-2007 Undergraduate Catalog Page 89-90

Disability Guidelines:
Park University is committed to meeting the needs of all students that meet the criteria for special assistance. These guidelines are designed to supply directions to students concerning the information necessary to accomplish this goal. It is Park University's policy to comply fully with federal and state law, including Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990, regarding students with disabilities. In the case of any inconsistency between these guidelines and federal and/or state law, the provisions of the law will apply. Additional information concerning Park University's policies and procedures related to disability can be found on the Park University web page: http://www.park.edu/disability .


This material is copyright and can not be reused without author permission.

Last Updated:5/17/2007 10:53:24 AM