Nursing-Managed Care
Read chapter 9 materials and complete the following in order for Managed Care:
o Managed Care Introduction
o Managed Care PowerPoint
o Health Insurance (video)
o Medicaid (video)
o Pay for Performance
o Genetic Testing
Complete Study:
1. In the managed care arena, what is capitation? Who are the “Gatekeeper” and their duties?
2. What are the alternative(s) to managed care? For Americans, what issues does managed care raise?
3. How do PPOs differ from HMOs?
4. Provide information on the HEDIS abbreviation, purpose, its responsibility to consumers, and its effects on quality in healthcare. Surf the Internet.
5. Continue your search to report on HEDIS to offer information and compare managed care providers. Go to: http://www.ncqa.org Search the website to learn about the data elements. Your goal will be to access performance for HEDIS Measures Effectiveness of Care:
a. Use the 2016-2020 Quality Measurement Report to briefly summarize the chronic diseases measured for:
• Adult BMI Assessment
• Lead Screening
• Cervical Cancer
6. Research Internet for Outpatient Clinical Documentation Improvement Program. Provide a brief overview. (Hint: You will be asked to research for discussion posting)
7. Search the Internet to determine the steps Managed Care organization are doing to prevent fraud and abuse among patients and health care providers. Address each party (patients and providers). You must list and explain at least three fraud and abuse tactic.
8. Determine the role of managed care in the health information exchange (HIE). Search the Internet to enhance your knowledge. Briefly discuss your understanding of HIEs. (Do not copy and paste)
9. Access the “Insurance Ranking” website on the Managed Care Websites listed in the lesson. Submit grid below and required data with Study Guide questions. On the last line, you choose a health plan located in Florida and submit findings in the Discussion Forum (specify why you choose the health plan):
