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HC 463 Third Party Reimburse & Risk Mgt
Pino, Ruben,, Jr.


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.

Course

HC 463 Third Party Reimburse & Risk Mgt

Semester

S2B 2009 BL

Faculty

Pino, Ruben, Jr.

Title

Adjunct Faculty

Degrees/Certificates

BS, Park University
MA, Health Services Management, Webster University

Office Location

Before or after class or by appointment.

E-Mail

ruben.pino@park.edu

Semester Dates

MARCH 21 - MAY 9 2009

Class Days

------S

Class Time

1:10 PM  - 6:10 PM

Prerequisites

None

Credit Hours

3


Textbook:
 

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

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/.


Course Description:
HC463 Third Party Reimbursement and Risk Management: 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:
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 =70 pts

Answering the weekly homework questions and essays. (place in Drop Box) =180 pts

Taking the Midterm Exam = 150 pts

Writing two summary articles on a current risk management topic =200 pts

Completing a Research Paper on the Risk Management process.  =350 pts 

Completing a power point presentation by a person in class = 50 pts

_____________

TOTAL POINTS                                                                                                                1000 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.

Grading Scale –

In-class writing assignments and class participation will constitute approximately 40% of your course grade.  This includes homework assignments, article summaries, peer review, and discussions.

A midterm exam covering  current issues presented in class, readings and the content of papers developed by students, will constitute 15% of your course grade.

The term paper presented in prescribed format will constitute 30% of your course grade and serving as your final exam.  Your paper is expected to be approximately six double spaced pages in length not including the reference and title pages.

Grading Criteria for Participation Points:

Each week homework and discussion assignments are worth 40 points each for a total of 260 points for the course.  Grading criteria for points on discussions and homework is as follows:

The three most important grading criteria for your work will be breadth, depth, and application of course concepts. For purposes of this course, the following definitions will apply to each of these terms:

  • Breadth (B):  Refers to the "number" of chapter and lecture concepts that you have applied to the homework questions, discussion, and report.
  • Depth (D):  Refers to the degree you provide "detailed" analyses to the homework questions, discussion, and report.
  • Application (A):  Refers to the chapter and lecture concepts you "apply" to your homework questions, discussion, and report. You can accomplish this by referencing page numbers, concepts such as data collection methods, etc.

Your participation grade will be determined by your positive responses to the discussion postings of others and your timeliness in terms of submitting your work, etc.

Article Summary (INSTRUCTIONS)
You will be writing a paper specifically related to the issues surrounding a current risk management topic. The summary article should be a topic other than the one covered in your research paper. Article Summaries and the original 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 risk management topic that is relevant to the risk management process being utilized by health care organizations 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 management topic  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 risk management issue relates to risk management practices currently utilized in health care organizations, government regulations, to HIPA regulations, and other risk management activities practiced in health care.

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.


GRADING CRITERIA
TOTAL POINTS

Summary of Article
10 Points

Reaction to Article
10 Points

Analysis of Article: Correlation to Course
15 Points

Format/Neatness(TYPED)
05 Points

Source Material
05 Points

College Level Writing Skill
05 Points

TOTAL POINTS
50 POINTS

A midterm exam and a final exam will be given over current issues presented in class, readings and the content of papers developed by students, and will constitute 20% of your course grade.

The research paper (APA FORMAT)presented in prescribed format will constitute 30% of your course grade, and is expected to be approximately 12-1 double spaced pages in length not including the reference and title pages.

Final paper: Write a paper about a current issue in Risk Management that is currently being utilized in health care organizations. Include in the paper:

1) The role of the risk management topic in health care organizations.

2) The role of the risk management topic as related to risk management processes utilized across the health 
 care spectrum.

3) How the risk management topic impacts the cost of health care, staffing capability, and other health care
    activities.

4) Explain how the risk management topic is related to the government regulatory environment. 

5) Describe involvement of interest groups and other health care organizations such as JCAHO in determining  the way risk  management is practiced in the United States.

6) Describe any strategies and recommendations necessary to implement this risk management topic or process
    in health care organizations today.

7) Include any impact the risk management topic or process would have on health care policy making today. 

GRADING OF PAPER: 300 Points

Approved Topic by the Instructor: 5 points

Title Page: 10 points

Introduction of Topic: 30 points

Body of Term Paper includes:

a) Role of political process on risk management: 30 points

b) Roles of the demanders and suppliers of health policy: 30 points
 Strategies and Recommendations for addressing healthcare issue: 20 points
 
c) How the risk management topic impacts the cost of health care, staffing capability, and other health care
    activities. 30 pts

d) Explain how the risk management topic is related to the government regulatory environment.  20 pts

e) Describe involvement of interest groups and other health care organizations such as JCAHO in determining  the way risk  management is practiced in the United States. 30 pts

f) Describe any strategies and recommendations necessary to implement this risk management topic or process
    in health care organizations today. 30 pts

g) Include any impact the risk management topic or process would have on health care policy making today. 
    30 pts


Effect of current issue on future initiatives in risk management: 30 points

Sources of information in body of paper are cited using APA style format: 10 points

Reference Page: 10 points

TOTAL POINTS: 300 points

Topics should be selected and approved by the end of Week One, but not later than the end of Week Two.

The entire term paper will be submitted at the end of Week Eight, for grading.

(There will be opportunity for revisions in each section, based on interaction with the professor and peer reviews until the end of Week 7.)

The research paper  must be completed and submitted Saturday of Week Eight by Midnight. Please check your calendar dates and arrange to complete the final accordingly.

The term paper will be written in English and in the APA format. An exact sample of the required format is posted at parkonline.org in the DOC sharing tab. The paper will be six pages in length, excluding the cover and reference page, double spaced, 12 font, Times New Roman. The paper will contain five references from credible library sources and obtained from Park University's online library resources. Students must run their "spell checker" and edit their paper for spelling, grammar, and punctuation errors prior to submitting the paper.

All papers will be submitted on parkonline.org in the provided "dropbox" where the paper can be uploaded in MS Word format. You must save your assingments/homework/quizes, etc in Rich Text Format (.rtf).

When possible, the student will complete quizzes online at parkonline.org

Grading:

Course Grading Scale 

  A = 900-1000 points

  B = 800-899   points

  C = 700-799   points

  D = 600-699   points

  F =      0-599   points

 


BREAKDOWN 


Quizzes                                                       70  points
Homework                                                 180 points
Article Summary                                       200 points

Midterm Exam                                          200 points
Power Point Presentation of Paper          100 points
Final Research Paper                               300 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 course grade for students will be based on the overall average of homework and tests taken during the course in accordance with the weighting of the various requirements as stated in the syllabus.

All final exams in all School of Business and Management courses will be comprehensive and will be closed book and closed notes. They will constitute 30% of the total course grade and will not be a take-home exam. They will be completed during the test week in the period designated by the registrar or by the Proctor in the case online courses. 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 Dean of the School of Business and Management.

Late Submission of Course Materials:

Work missed because of absences or work turned in late will not be accepted.  It is your responsibility to meet deadlines and turn in work when it's due. Military students can make alternative arrangements with the instructor because of deployments or other unforeseen military duties that often arise. Park University specializes in serving military students and accomodations will be made to help the soldier, marine, airman, or sailor complete the course successfully.

Classroom Rules of Conduct:

Students are expected to read the assigned textbook chapters and to be familiar with their chapter content before each class session.  Plagiarism and unauthorized collaboration on class work, or cheating is considered a serious violation by Park University and is not tolerated.  Students may be dismissed or given a failing grade if found cheating or plagiarizing.  Absences should be kept to a minimum.  If an absence is necessary then students will receive a letter grade deduction from the final score whether the absence is excused or unexcused.  Leveling work for absences may include detailed written summaries of chapters or completion of review questions or definitions at the end of chapters, or any other class-related assigned task as determined by the instructor.  Late class work will not be accepted.  Tardiness over thirty minutes, or failure to attend the entire class will be considered an absence.  Two unexcused absences will be reported immediately to the Park University administrative office for appropriate action.

 
Attend all classes for the entire class period and be on time to all classes. Roll will be taken before and after at each class meeting, therefore students who leave during class breaks will be considered absent and receive a "U". If classes are missed for a legitimate reason such as temporary duty or illness the student is responsible to make up the missed work, obtain lecture notes and handouts. If you are going to miss a class, I expect to be communicated with prior to class, if possible. Assignments must be turned in on time. Participate in classroom discussions. Be respectful when others are speaking and do not interrupt. Turn off cell phones and pagers during class period. Please do the online survey after the course completion.

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 .

Assignments

Study Chaptersrs 1-4 and read the posted lecture/powerpoints.

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.

Assignments

Study Chapters 5-7 and read the posted lecture/powerpoints.

Participate in weekly discussion article thread.

Complete weekly assignments.

Complete weekly quiz.

 

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.

Assignments

Study Chapters 13-15 and read the posted lecture/powerpoints.

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?

Assignments

Study Chapter 21 and read the posted lecture/powerpoints.

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.

Assignments

Study Chapter 22 and read the posted lecture/powerpoints.

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.


Assignments

Study Chapters 24-27 and read the posted lecture/powerpoints.

Participate in weekly discussion article thread.

Complete weekly assignments.

Complete weekly quiz.


Week 7
Current Risk Managment Topic

Assignments

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.

GRADING CRITERIA
TOTAL POINTS

Summary of Article
10 Points

Reaction to Article
10 Points

Analysis of Article: Correlation to Course
15 Points

Format/Neatness
05 Points

Source Material
05 Points

College Level Writing Skill
05 Points

TOTAL POINTS
50 POINTS

Take weekly quiz

Turn in research paper final draft

Week 8 Risk Management Today

Assignments

Please go back and read your past classroom 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 classroom discussion.

Take your Final Exam.

Complete course evaluation.

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 2008-2009 Undergraduate Catalog Page 87

Plagiarism:
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 2008-2009 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 "F".
  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.

Park University 2008-2009 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 .

Copyright:

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

Last Updated:2/27/2009 6:05:24 PM