Third Party Reimbursement and Risk Management
Phillip L. Sims, Instructor
3 January through 23 February 2005
Monday and Wednesday, 1700 to 1930
Fort Bliss, Texas
I. 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.
II. GOALS OF THE COURSE
The course is designed so that the student will have a better understanding in and of
the role health insurance has in the shaping of services provided by institutions and
physicians. The course will cover a wide variety of subjects dealing with prepaid
health plans, risk management, and loss prevention.
III. LEARNING OBJECTIVES
To provide an overview of the history, evolution, and development of health
insurance programs geared toward individuals and groups.
IV. COURSE ARRANGEMENTS
Lecture / conference Lecture review
Research paper Research presentation
Examination (mid-term) Final Examination
V. COURSE REQUIREMENTS
Paper. A paper will be required of all students. The paper will be at least seven (7)
pages long (not including the index and bibliography), typed and double spaced.
The paper will deal with a subject in relation to the course and agreed upon
between the student and the instructor.
Paper presentation. Each student will prepare a 3 to 5 minute oral presentation
that will provide an overview of the paper the student researched on a subject
dealing with health insurance or risk management. These research papers will be
presented during class with specific dates and times to be discussed in class.
VI. COURSE TEXT
Principles of Risk Management and Insurance, 9th Edition, G. Rejda, Addison-
Wesley Publications, 1998
VII. SUPPLEMENTAL RESOURCES
Medical Care and Health Insurance, J. F. Follman, Jr., Irwin, Inc., 1985
VIII. CLASS MEETING AND EXAMINATION SCHEDULE
1-3 Administrative announcements, discussion of the syllabus, lecture/discussion on
history and types of health insurance. Chapters 1 & 2, Risk in our society.
Insurance and risk.
1-5 Discuss Chapter 3 and 4. Introduction to risk management. Advanced topics in
1-10 Discuss Chapters 5 and 6. Fundamental legal principles. Analysis of insurance
1-12 Discuss Chapters 7, 8, and 9. The liability risk. Homeowners insurance I and II.
1-17 Discuss Chapters 10, 11, and 12. Automobile insurance. Automobile insurance
and society. Other property and liability insurance.
1-19 Discuss Chapters 13 and 14. Commercial property insurance. Commercial
1-24 Discuss Chapters 15 and 16. Crime insurance and surety bonds. Fundamentals of
life insurance. Review for mid-term examination.
1-26 Mid-term Examination, Chapters 1 through 16.
1-31 Discuss Chapters 17 and 18. Types of life insurance. Life insurance contractual
2-2 Discuss Chapters 19 and 20. Buying life insurance. Annuities and individual
retirement accounts. Student presentations.
2-7 Discuss Chapters 21 and 22. Individual health insurance coverages. Employee
benefits. Student presentations.
2-9 Discuss Chapters 23 and 24. Retirement plans. Social insurance. Student
2-14 Discuss Chapters 25 and 26. Types of insurers. Insurance company operations.
2-16 Discuss Chapter 27 and 28. Insurance pricing. Government regulation of
Insurance. Student presentations. Review for final examination.
2-21 Final examination. Chapters 17 through 28.
2-23 Review of final examination. Make-up student presentations.
IX. CLASS POLICIES
Students are expected to come to all classes and be on time. Roll will be checked . at each class meeting. Classes missed for legitimate reasons, such as illness,
temporary duty, are excusable; however, the student must make up the missed
work. The student is responsible for providing the instructor with justification for
an excused absence either prior to or immediately after the absence. Two un-
excused absences are excessive and three unexcused absences will result in an
involuntary withdrawal and a grade of “F” (attendance) for the course
X. ACADEMIC HONESTY
Submitting someone else’s work as your own will not be tolerated. If determined
by the instructor that academic dishonesty has occurred in any part of the course,
the student(s) involved will normally be given an immediate grade of F and
dropped from the course. The second violation results in automatic expulsion
from the school. The Assistant Vice President will be notified in writing of the
XI. GRADING POLICY
The final course grade will be determined using the following measurements:
Mid-term Exam 30%
Final Exam 30%
Comprehensive Cases (Paper) 30%
Research Presentation 10%
Mid-term exam will cover Chapters 1 through 16. Final Exam Chapters 17
The comprehensive case (paper) must be typewritten and submitted at the last
lecture prior to the final examination unless previously coordinated with the
instructor. Late papers will be marked down accordingly and a failing grade
assigned if not submitted before the final examination.
The following will be used to assign course letter grades:
90 - 100 A
80 - 89 B
70 - 79 C
60 - 69 D
Below 60 F (for three or more unexcused absences)