Why a Managed Care Academy?

Rose Leidl, RN, is an expert in managed care, and she concurs with the industry consensus that training in this field is a vital, nationwide need – one that is not being met.

Managed care has imperfectly defined the delivery of modern healthcare in the world, and managed care principals are the theoretical core of our modern healthcare systems. However, in the U.S.A, there exists a significant training gap among clinical and non-clinical healthcare professionals in terms of a boots-on-the-ground, working knowledge of managed care operations. Based upon her observations during audits of over 100 health plans, Ms. Leidl has decided that now is the time to do something about it.

Utilizing her firm’s physicians, nurses, mental health specialists and regulatory experts, who have a wealth of knowledge to share about managed care, Ms. Leidl is launching a Managed Care Academy (MCA). The curriculum will be based on the following major cornerstones of managed care operations – utilization management, quality management, enrollee grievances and appeals, and access and availability of services.


  1. Utilization Management (UM)

Utilization management is a critical component of managed care because of its central role in approving and denying healthcare services. By ensuring that cost-effective care is medically appropriate and safe, UM functions as the concierge of managed care.

UM in the healthcare industry is most notably recognized for day-to-day monitoring of service delivery, enrollment and institutional capacity. In particular, UM is responsible for monitoring and reporting on over- and under-utilization of specialty care, which demonstrates how referrals to specialists and diagnostic and treatment modalities reflect a health plan’s quality of care and cost effectiveness. However, UM’s reach goes far beyond these functions, affecting other elements of managed care. If done properly, UM influences the workings of diverse administrative functions and departments, such as member services, provider relations, human resources and regulatory affairs.

As an acknowledged expert in utilization management, Ms. Leidl will lead this module. At the end of the program, academy graduates will be able to:

  • Identify Knox Keene Act (KKA) citations that regulate health plan managed care decisions
  • Evaluate the application of clinical criteria to authorization decisions and write denial letters to enrollees and providers in a way that effectively ties the decision to the clinical criteria, and most importantly, ties the clinical criteria to the patient’s medical condition
  • Develop policies and procedures that reflect both organizational practice and regulatory requirements
  • Identify discrepancies between practice, policy and regulation that may result in audit deficiencies
  • Construct data analysis tools that provide actionable information on important UM processes, including over- and under-utilization of services
  • Manage the process of an authorization request for a healthcare service from the provider’s initial request to health plan approval or denial, to the health plan’s appeals process, and to a complaint submitted to a regulator for adjudication.
  1. Quality Management (QM)

Quality management (also called quality improvement and quality assurance) in health plans, health systems and hospitals is charged with ensuring the provision of quality care by physicians and other healthcare professionals. As a result, QM activities must be overseen by physicians in medical plans, by ophthalmologists in vision plans, by psychiatrists in mental health plans, and by dentists in dental plans. QM is the ultimate watchdog of managed care.

QM involves monitoring and investigation of specific quality of care cases across provider networks and health plans. Network monitoring, conducted as part of the UM, GA or AA process, can reveal overarching quality issues that may need to be resolved through policy and procedure changes or training. Network monitoring also uncovers specific incidents where a provider’s patient care and service level is questionable, often called potential quality issues  or “PQIs,” which require investigation and a corrective action plan (CAP) where the investigation confirms deficiencies in care or service. PQI activities are usually overseen by a quality management committee, using specific agreed-upon evaluation measures (e.g., outcome severity levels). Corrective action can range from warning letters to expulsion from the provider network and reporting to regulatory review agencies.  

MHU physician staff will lead this module. At the end of the program, academy graduates will be able to:

  • Collaborate with other managed care departments so that important QM issues are identified, addressed and followed up
  • Analyze patterns and trends from various sources and alert the health plan, facility or provider group to potential quality of care issues
  • Select meaningful quality improvement projects, conduct a study, and report on the results
  • Identify individual cases that may present potential quality of care issues
  • Understand the steps in a QM investigation, and formulate a corrective action plan, when indicated
  • Understand the steps in a CAP, launch a CAP, ensure that the CAP has been implemented by the provider, and follow up to assess the effectiveness of the CAP
  1. Grievances and Appeals (GA)

A health care organization’s handling of enrollees’ grievances/complaints and appeals is a lens into to organizational performance. If a health plan or provider rebuffs or dismisses enrollee complaints or considers them to be nuisance calls, quality of care suffers. GA serves the same purpose as the canary in the coal mine.

GA departments have several key functions. The customer service representative (CSR) serves as the front line, and a knowledgeable managed care executive knows that consistent, in-depth training and monitoring of CSRs is of primary importance. Other key functions in GA management are the informed analysis of grievance categories and identification of potential quality and service issues for further investigation (e.g., review by clinical staff). Focused analysis of GA data can initiate policy and procedure revision across the organization, and the investigative process can serve as a corrective tool. By its nature, GA  facilitates communications issues between enrollees and other organizational units, which can impact organizational success.

Accomplished and experienced MHU clinical and non-clinical managed care experts will lead this module, which will focus on the tasks that result in effective management of the GA process. At the end of the program, academy graduates will be able to: 

  • Develop training policies and procedures for managed care GA departments
  • Articulate the steps in grievance investigations
  • Oversee development and management of data analysis systems for GA that weed out quality issues for further review and identify trends and patterns that suggest system-wide problems
  • Utilize the internal overturn rates in the appeals process to construct better decision-making with regard to authorizing and denying services
  • Collaborate with other organizational units on improving communications between enrollees, providers and administrators based on GA interactions
  1. Access and Availability (AA)

Access to care addresses the obstacles that enrollees experience in obtaining the services that they have contracted with a health plan to provide. These issues often involve geographic barriers or an insufficient volume and diversity of providers in the plan’s network. In particular, lack of access to specialty care can seriously compromise health and well-being. Availability of care addresses barriers to an enrollee’s ability to obtain care from providers as a result of inordinate wait times to schedule appointments, tests and procedures as well as wait times in providers’ offices. AA is the timekeeper with regard to delivery of health care services.

For many years, DMHC and MHU struggled with individual health plan and provider interpretations of acceptable parameters for access and availability of services. For instance, one health plan may have established a 200-mile roundtrip standard for an enrollee traveling to an in-network specialist in a rural area, while another plan may have established a more appropriate 50-mile roundtrip standard. One health plan may have established a four-week wait for an initial obstetrical appointment, whereas another plan may have established a two-week standard.

In 2010, the Department of Managed Health Care was charged with enforcing Timely Access Regulations (TAR). These regulations identify permissible wait times for the various types of health care appointments as well as enrollee telephone inquiries and provider call-backs. MHU designed the survey format for these standards, which are reviewed during regulatory audits of health plans.

MHU Vice President Pat Schano, MEd, who worked with the Department on the TAR regulations, will lead this module. The MHU team will present and discuss the Timely Access Regulations so that academy graduates will:

  • Be able to develop prospective AA standards using the California TAR as an example
  • Understand how AA standards can be harnessed by health plans and providers
  • Oversee data collection mechanisms and produce AA reports
  • Evaluate the delivery of health care services based on exemplar AA standards

Good managed care is achieved when these four key components – utilization management, quality management, grievances and appeals, and access and availability –  come together like the parts of a smooth-running engine. Training is the only way to achieve this goal.

S5 Box



You need to enable user registration from User Manager/Options in the backend of Joomla before this module will activate.