Introduction

Managed care and health insurance are integral components of modern healthcare systems, aiming to provide cost-effective, high-quality care while ensuring financial sustainability. This course provides professionals with the knowledge and tools to navigate managed care models, health insurance regulations, provider network management, and reimbursement strategies. Participants will also explore digital transformation, risk assessment, and the future of value-based healthcare.

Course Objectives

By the end of this training, participants will be able to:

• Understand the principles of managed care and health insurance.
• Analyze different managed care models and reimbursement structures.
• Navigate health insurance regulations, policies, and compliance requirements.
• Optimize provider networks, claims processing, and cost containment.
• Leverage data analytics and AI in managed care decision-making.
• Assess financial risks, fraud prevention, and reimbursement strategies.
• Explore future trends and innovations in health insurance and managed care.

Who Should Attend?

This course is ideal for:

• Healthcare administrators and managed care professionals
• Insurance executives and claims processing specialists
• Physicians, hospital managers, and healthcare providers
• Policy makers and healthcare regulators
• Finance and risk management professionals in healthcare
• Entrepreneurs and consultants in health insurance and managed care

Course Outline

Day 1: Introduction to Managed Care and Health Insurance

• Overview of the Managed Care System
• Health Insurance Models: HMO, PPO, EPO, POS, and ACOs
• The Role of Government and Private Insurance in Healthcare
• Key Regulations and Compliance Frameworks (HIPAA, ACA, GDPR)
• Ethical Considerations in Managed Care and Health Insurance

Day 2: Provider Network Management and Reimbursement Strategies

• Contracting and Negotiations with Healthcare Providers
• Fee-for-Service (FFS) vs. Value-Based Reimbursement Models
• Capitation, Bundled Payments, and Pay-for-Performance Models
• Claims Processing, Billing, and Coding in Managed Care
• Case Study: Optimizing Reimbursement and Cost Containment

Day 3: Risk Management, Fraud Prevention, and Cost Control

• Risk Assessment and Actuarial Science in Health Insurance
• Identifying and Preventing Insurance Fraud and Abuse
• Utilization Review and Cost Control Strategies
• Managing Denials, Appeals, and Claims Audits
• Case Study: Successful Risk Mitigation in Health Insurance

Day 4: Digital Transformation and AI in Managed Care

• The Role of AI and Big Data in Health Insurance Analytics
• Telemedicine and Its Impact on Managed Care Models
• Wearable Health Tech and Remote Monitoring in Insurance Plans
• Blockchain and Cybersecurity in Health Insurance Data Protection
• Case Study: Successful Digital Innovation in Health Insurance

Day 5: Future Trends and Strategic Planning in Managed Care

• The Future of Value-Based Care and Alternative Payment Models
• Global Trends in Health Insurance and Managed Care Evolution
• Leadership and Change Management in Health Insurance Companies
• Group Project: Developing a Managed Care Strategy for a Healthcare System
• Course Wrap-Up, Q&A, and Certification