Introduction to Managed Care for New Hires

Introduction to Managed Care for New Hires

This course describes the “nuts and bolts” of managed care and thoroughly covers the issues surrounding payer contract analysis and negotiation. Selected modules from this course are valuable for management and clinicians throughout a hospital or health system as an on-site private course or through an association as a membership learning activity.


  • In introduction to 22 managed care models (HMO, PPO, POS) and payer organizations
  • Understanding carve-outs, inpatient stop-loss, short-stay stop-loss, and withhold pools
  • An overview of various payment models implemented around the nation
  • How to engage physicians in utilization and quality of care documentation and analysis
  • Pre-negotiation preparation
  • Key negotiation strategies via email, by phone and face-to-face
  • Understanding how payers evaluate their risks through actuaries and underwriters and retrospective claims analysis
  • Preparing for outcomes-based reimbursement and pay-for-performance program incentives
  • A discussion of recent legislative changes and proposals affecting Medicare Advantage Programs


Course participants will

  • Identify key factors that influenced the changes in managed care organizations
  • Understand the various managed care models and relevant state and federal regulations
  • Key issues surrounding insurer medical cost ratio (MCR) or medical loss ratio (MLR) statistics
  • Understand various cost-sharing innovations and strategies used by payers, health facilities, and employers in managed care agreements
  • Learn how coordination of benefits works with Medicare, Medicare Advantage, TRICARE, Medicare Secondary Payer, Medicaid, Auto Accident, Work comp and Travel Insurance
  • Learn an overview of the various reimbursement strategies by payers to pay physicians
  • How to succeed and grow profits under capitated payer arrangements
  • How to succeed and grow profits and mitigate untoward risk under fully-inclusive bundled case rate arrangements
  • Know what to expect in a typical payer or employer-direct contract negotiation process
  • How case management and care navigation improve care delivery while reducing overall health delivery costs
  • Understanding IPAs, PHOs, MSOs and ACOs: Why they exist, how things can go sideways for a network in very short order
  • Understanding NCQA: Its market influence, crosswalks of certain key standards for health plans that providers must know and understand
  • Explain the effects of healthcare supplier and facility branding and increased consumer sophistication
  • Learn what to make of outcomes-based reimbursement offers and key incentives related to pay-for-performance programs: Questions to ask; How to decide


Pricing: $799

Instructional Method: Master Class (Training, Q&A, Practicum, Critique) NOTE: Class size is limited to ensure individual attention for each participant.

Designed for: New hires in revenue management and managed care with 5 years' experience or less; physicians, therapists, ASC and hospital leadership, new board members, individuals responsible for denied claims appeals and contract performance decision support and audit.

Prerequisites: None

Advance Preparation: None

Level: Intermediate

Course Availability: Scheduled dates and on-demand by healthcare organizations and associations

Format: Classroom

Fields of Study: 

  • Specialized Knowledge: 14.0 hours
  • Total hours: 14.0

What's Included with Registration:

  • Course materials on USB Drive
  • Signed copy of The Managed Care Contracting Handbook, 2nd Edition by Maria Todd ($85 retail value)
  • Hot breakfast each day of class ($30 value)
  • Hot lunch each day of class ($36 value)
  • Break refreshments
  • Free Wi-Fi access
  • Waiver of Resort Fee at the hotel ($30 value)
  • Round trip airport transportation (from SGU) when staying at Red Mountain Resort ($70 value)

Venue: Red Mountain Resort and Spa

Reservations: Contact Lindy Overton 435-652-5744 for special room rates for this event.

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