HC463 Third Party Reimburse & Risk Mgt

for S1B 2011

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HC 463 Third Party Reimburse & Risk Mgt


S1B 2011 BL


McGee, Jacqueline Y


Adjunct Faculty


Master of Arts Health Care Management, Webster University

Office Hours

By Appointment

Daytime Phone




Semester Dates

January 10, 2011through March 6, 2011

Class Days


Class Time

7:40 - 10:10 PM

Credit Hours



Rejda, Principles of Risk Management and Insurance, 11th Edition
ISBN 978-0-13-611702-5

Textbooks can be purchased through the MBS bookstore

Textbooks can be purchased through the Parkville Bookstore

Additional Resources:
Publication Manual of the American Psychological Association, 6th Edition.

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

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:
Classroom discussions, review questions and presentations, examinations and final paper.


Classroom Discussion                   100 points
Mid Term                                    250 points
Review Questions (6 at 33.3)       200 points
Final Paper                                   150 points
Final Examination                          300 points
                                                   1,000 points
A = 1000-900
B = 899- 800
C = 799-700
D = 699-600
F = 599-and below

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 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.

Late Submission of Course Materials:
Students are responsible for ensuring timely submission of their coursework. If circumstances arise, it is the student's responsibility to discuss the issues ahead of time with the instructor. Assignments will be considered late if submitted 24 hours after the due date. Any work submitted late will be deducted one (1) point for each day for up to five (5) days past the due date. Assignments will not be allowed after the five days resulting in zero points.

Classroom Rules of Conduct:
Students will act in a mature and appropriate manner at all times. Students will arrive on time for class and will be prepared for the lesson outlined. Cell phones will be turned off.

Course Topic/Dates/Assignments:

1/10 Administrative announcements, course explanation and review of course objectives.

Read chapters 1 & 2

What is Risk?

1. Discuss the relative variation of actual loss from expected loss

2. Describe the change of loss and the objective and subjective probability.

3. Apply the concept of peril and hazard in risk management.

4. Explain the basic characteristic of insurance.

5. Describe the Characteristics of an ideally insurable risk from the viewpoint of a private insurer.

6. Describe the major types of insurance.

1/12 Read chapter 3 & 4

Introduction to Risk Management

1. Define risk management and explain the objectives of risk management.

2. Describe the steps in risk management process

3. Explain the major risk control techniques including


Loss Prevention

Loss reduction

4. Apply the principles of risk Management to a personal risk management program.

5. Explain the meaning of financial risk management and enterprise risk management.

6. Describe the impact of the underwriting cycle and consolidation in the insurance industry on the practice of risk management.

7. Show the financial analysis can be applied to risk management decision making.

Homework 1: Review questions: Chapter 1 answer 1-6 and Chapter 2 answer 6-10, Chapter 3 questions 1-5 and Chapter 4 answer all the even numbers. Questions need to be submitted electronically by midnight 1/15/2010. Grade will drop one (1) letter grade if not submitted on time

1/17 Read chapter 5 & 6

Types of Insurers and Marketing System

1. Describe the major types of private insurers, including the following:

Stock insurers Lloyd’s of London

Mutual insurers Blue Cross and Blue Shield plans

Reciprocal exchanges Health maintenance

2. Explain why some life insurers have demutualized or formed holding companies I recent years.

3. Describe the direct response system for selling life insurance.

4. Explain the ratemaking function of insures

5. Explain the steps in the underwriting process.

6. Describe the steps in the process of settling a claim.

7. Explain the reasons for reinsurance and the various types of reinsurance treaties.

1/19 Read Chapter 7 & 8

Financial Operations of I insurers and Government Regulation of Insurance

1. Describe the three major sections of the balance sheet for a property and casualty insurance company: assets, liabilities, and policyholders’ surplus.

 2. Explain and identify the sources of revenues and types of expenses incurred by a property and causality insurance company.

3. Explain the major reasons why insures are regulated.

4. Identify key legal cases and legislative acts that have had an important impact on insurance regulations.

5. Explain the objectives of rate regulations and the different types of rating laws.

6. Explain the major arguments for and against state regulation of insurance

Homework 2: Review questions Chapter 5 answer 1-6, Chapter 6 questions 6-10, Chapter 7 answer all even, and Chapter 8 answer 6-10. All answers need to be typed and submitted electronically by midnight 1/22/2010. Grade will drop one (1) letter grade if not submitted on time.

1/24 Read Chapter 9 and 10

Legal Principle in Risk and Insurance

1. Explain the fundamental legal principles that are reflected in insurance contracts, including

Principles of indemnity

Principle of insurable interest

Principle of subrogation

Principle of utmost good faith

2. Describe the basic requirements for the formation of a valid insurance contract

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

4. Identify the basic parts of any insurance contract

5. Explain the meaning of "insured" in an insurance contract.

6. Explain how coinsurance works in a property insurance contract

7. Explain how losses are paid when more than one insurance contract covers the same loss.

1/26 Read Chapter 11 and 12

Life and Health Risk

1. Explain the meaning of premature death.

2. Describe the financial impact of premature death on different types of families.

3. Explain the needs approach for estimating the amount of life insurance to own.

4. Describe the basic characteristics of current assumption life insurance.

5. Explain the dividend options that typically appear in participating life insurance policies

6. Describe the various settlement options for the payment of life insurance death benefits

7. Describe the following riders that can be added to a life insurance policy:

Waiver of premium Cost of living rider

Guaranteed purchase option Accelerated death benefits rider

Accidental death benefit rider

Final Papers: Students should give topic and date for presentation

Homework 3: Review questions Chapter 9 answer 1-6, Chapter 10 questions 6-10, Chapter 11 answer all even, and Chapter 12 answer 6-10. All answers need to be typed and submitted electronically by midnight 1/29/2010. Grade will drop one (1) letter grade if not submitted on time.

1/31 Read Chapter 13 and 14

Life and Health Risk

1. Explain the defects in the traditional net cost method for determining the cost of life insurance.

 2. Explain the interest adjusted surrender cost index and net payment cost index for determining the cost of life insurance.

3. Describe the suggestion to follow when purchasing life insurance.

4. Describe the basic characteristics of a fixed annuity and variable annuity.

5. Explain the major characteristics of an equity index annuity

6. Explain the basic characteristics of a Roth IRA

7. Explain the income tax treatment of a traditional IRA and a Roth IRA.

Review for Mid-term on Chapters 1-12

2/2 Mid Term examination

2/7 Read Chapter 15-16

Legal Principle in Risk and Insurance

1. Explain the major health care problems in the United States.

2. Describe the basic characteristics of individuals major medical insurance

3. Identify the basic characteristics of health savings accounts (HAS).

4. Describe the key characteristics of long-term care insurance.

5. List the guidelines to follow when purchasing individual health insurance

6. Explain the underwriting principles followed in group insurance.

7. Describe the basic characteristics of the following group medical expense plans:

Basic medical expense insurance

Major medical insurance

Dental insurance

8. Describe the major characteristics of cafeteria plans.

2/9 Read Chapter 17 and 18

Life and Health Risk

1. Explain the basic features of private retirement’s plans, including:

Minimum age and service requirements

Retirement ages

Vesting rules

2. Distinguish between defined-contribution and defined benefit retirement plans

3. Describe the basic characteristics of Section 401(k) plans.

4. Explain the major features of profit-sharing plans

5. Identify the major features of SIMPLE retirement plans for small employers.

6. Explain the reasons why social insurance programs are established.

7. Describe the basic characteristics of social insurance programs

8. Identify the major benefits under the Medicare Program

Homework 4: Review questions Chapter 13 answer 1-6, Chapter 14 questions 6-10, Chapter 15 answer all odd number, and Chapter 16 answer 6-10. All answers need to be typed and submitted electronically by midnight 1/12/2010. Grade will drop one (1) letter grade if not submitted on time.

2/14 Chapter 19 and 20

Personal Property and Liability Risks

1. Define negligence and explain the elements of negligence.

2. Apply the law of negligence to specific liability situations

3. Explain the defects in the current tort liability system and the proposal for tor reform

4. Explain the following tort liability problems

Defective tort liability system

Medical malpractice crisis

Corporate fraud and lax corporate governance

5. Identify the major homeowners’ policies for homeowners, condominium owners, renters.

6. Explain the insured’s duties after a loss occurs.

7. Explain and give an illustration of the loss settlement provisions in the Homeowners 3 Policy.

2/16 Chapter 21 and 22 Policy Modifications:

1. Explain the medical payments to other coverage found In Section II of the homeowners’ policy

2. Identify the major exclusion that applies to the Section II coverage in the homeowners.

3. Explain the suggestions that consumers should follow when shopping for a homeowner’s policy.

4. Identify the parties that are insured for liability coverage under the Personal Auto Policy (PAP)

5. Describe the liability coverage in the PAP.

6. Explain the coverage for damage to your auto in the PAP.

7. Explain the duties imposed on the insured after an accident or loss.

Homework 5: Review questions Chapter 17, answer 5-10, Chapter 18 questions 1-6, Chapter 19 answer all even, and Chapter 20 answer 6-10. All answers need to be typed and submitted electronically by midnight 1/19/2010. Grade will drop one (1) letter grade if not submitted on time.

2/21 Chapter 23 and 24

1. Describe each of the following approaches for compensating auto accident victims:

Financial responsibility laws Compulsory insurance law

Unsatisfied judgment fund Uninsured motorists coverage

Low cost auto insurance "No pay, No play" laws

2. Explain the meaning of no fault auto insurance and the rationale for no fault insurance laws.

3. Identify the major factors that determine the cost of auto insurance to consumers.

2/23 Chapter 25 and 26

Commercial Property and Liability Risks

1. Explain the basic provisions in the building and personal property coverage form, including

Covered property Optional coverage

Additional coverage Extensions of coverage

2. Explain how a business income loss is determined under the business income (and extra expense) coverage form.

3. Identify the types of property that can be covered by an inland marine insurance policy.

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

5. Describe the basic coverage provided by the commercial general liability policy.

6. Explain the coverage provided by a workers’ compensation and employer’s liability policy.

7. Describe the basic characteristics of a professional liability policy for physicians.

2/28 Chapter 27

Commercial Property and Liability Risks

1. Define theft, robbery, burglary and safe burglary

2. Identify the insuring agreements in the commercial crime form (loss-sustained form).

3. Explain the difference between the discovery form and the loss-sustained form.

4. Show how surety bonds differ from insurance.

Homework 6: Review questions Chapter 21, answer 5-10, Chapter 24 questions 1-6, Chapter 25 answer all even, and Chapter 26 answer 6-10. All answers need to be typed and submitted electronically by midnight 1/26/2010. Grade will drop one (1)  letter grade if not submitted on time.

Students will submit their final paper.

Review for final will cover chapters 13-27

3/2 Final Examination

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 students and faculty members are encouraged to take advantage of the University resources available for learning about academic honesty (www.park.edu/current or http://www.park.edu/faculty/).from Park University 2010-2011 Undergraduate Catalog Page 92

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. from Park University 2010-2011 Undergraduate Catalog Page 92-93

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 2010-2011 Undergraduate Catalog Page 95-96

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 .


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Last Updated:11/30/2010 4:06:29 PM