Introduction

Health insurance and managed care play a critical role in ensuring access to healthcare services, cost control, and financial sustainability for both healthcare providers and patients. As healthcare systems evolve, professionals must understand the complexities of insurance models, managed care organizations (MCOs), reimbursement mechanisms, and regulatory frameworks.

This five-day training course provides a comprehensive exploration of health insurance structures, managed care strategies, risk-sharing models, payment methodologies, and regulatory policies. Participants will learn how to navigate insurance reimbursement, optimize financial performance, and improve healthcare delivery through managed care systems.

Course Objectives

By the end of this course, participants will:

• Understand the fundamentals of health insurance and managed care models
• Analyze reimbursement methodologies and their impact on healthcare organizations
• Learn how risk management and actuarial principles influence health insurance
• Explore contracting strategies between payers and providers
• Gain insights into value-based care and alternative payment models
• Examine policy and regulatory frameworks governing health insurance
• Assess the impact of health insurance on healthcare access and patient outcomes

Who Should Attend?

This course is designed for:

• Healthcare administrators and executives
• Insurance professionals and managed care specialists
• Hospital CFOs and financial managers
• Physician practice managers and medical directors
• Policy analysts and healthcare consultants
• Revenue cycle managers and reimbursement specialists
• Government officials involved in healthcare regulation

Course Outline

Day 1: Foundations of Health Insurance and Managed Care

Introduction to Health Insurance

• Evolution of health insurance models
• Types of health insurance: private, public, employer-sponsored, and self-funded
• Key stakeholders: insurers, providers, employers, and government agencies

Understanding Managed Care Models

• Health Maintenance Organizations (HMOs) vs. Preferred Provider Organizations (PPOs)
• Exclusive Provider Organizations (EPOs) and Point of Service Plans (POS)
• Case study: Comparing managed care models across different healthcare systems

Workshop: Evaluating Insurance Plans

• Participants will assess different insurance plan structures and coverage options

Day 2: Reimbursement Models and Financial Strategies

Healthcare Reimbursement Mechanisms

• Fee-for-Service (FFS) vs. Capitation
• Bundled Payments and Pay-for-Performance (P4P)
• Case study: Transitioning from FFS to Value-Based Reimbursement

Risk Management in Health Insurance

• Risk pooling and risk adjustment methodologies
• Actuarial principles in healthcare insurance pricing
• Case study: How insurers manage risk in high-cost patient populations

Workshop: Analyzing Reimbursement Models

• Participants will compare different payment structures and their impact on providers

Day 3: Contracting, Negotiation, and Regulatory Compliance

Provider Contracting and Network Management

• Contracting strategies between insurers, hospitals, and physician groups
• Negotiating capitated vs. fee-for-service agreements
• Case study: Negotiating an MCO contract for a hospital system

Healthcare Regulations and Compliance

• HIPAA, Affordable Care Act (ACA), and Medicare/Medicaid policies
• State vs. federal regulations in managed care
• Case study: Compliance challenges in Medicare Advantage plans

Workshop: Drafting a Managed Care Contract

• Participants will develop key contract terms for provider-payer agreements

Day 4: Value-Based Care and Population Health Management

Transitioning to Value-Based Care

• Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs)
• Incentivizing quality and cost efficiency in healthcare delivery
• Case study: Implementing value-based care in a managed care setting

Population Health Management and Preventive Care

• Leveraging data analytics for population health strategies
• Chronic disease management programs in managed care
• Case study: Using predictive analytics for cost reduction in managed care

Workshop: Designing a Value-Based Care Model

• Participants will create a reimbursement model based on quality metrics

Day 5: The Future of Health Insurance and Managed Care

Technology and Innovation in Managed Care

• Role of Artificial Intelligence (AI) and big data in claims processing
• Telemedicine and its integration into health insurance coverage
• Case study: Digital health initiatives in managed care

Future Trends in Health Insurance and Managed Care

• The impact of healthcare policy reforms on insurance markets
• Global managed care models and lessons for the future
• Case study: The evolving landscape of employer-sponsored health insurance

Final Project: Designing a Managed Care Strategy

• Participants will present a strategic managed care plan
• Expert panel feedback and discussion

Closing Session and Certification

• Key takeaways and industry best practices
• Certification of completion