Role of Managed Care Organizations Within Health Care and Risk Management Programs.
QUESTION
The purpose of this assignment is to analyze the role of managed care organizations within health care and risk management programs.
Reflect on and evaluate the role that the managed care organization (MCO) plays in today’s health care environment by developing a 250‐500-word response that addresses the following:
1-What is a health care organization’s administrative role in executing risk management policies and ensuring compliance with managed care organization (MCO) standards?
2-What value do the regulatory statutes of a typical MCO provide to a health care organization? Consider how strategies pertaining to policies such as conflict resolution and risk management affect patients as well as employees and employers.
3-What MCO responsibilities relevant to the Patient Protection and Affordable Care Act (ACA) and Center for Medicare and Medicaid Services (CMS) focus on fraud, waste, and abuse laws?
Role of Managed Care Organizations Within Health Care and Risk Management Programs.
ANSWER
Role of Managed Care Organizations Within Health Care and Risk Management Programs.
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Introduction
Managed Care is a practice in HealthCare that finances. It delivers healthcare services while reducing costs and ensuring and improving the quality of services provided is up to standard through managing the provider network, utilization management and quality assurance. Managed-care plans have agreements with Healthcare providers and medical facilities to offer medical services at reduced costs. These healthcare facilities are what constitute the plan’s network.
The extent to which the plan pays is determined by the plan’s network’s internal rules.
Execution of risk management parameters and compliance checks by Healthcare Facilities – for Managed Care Organizations.
Healthcare organizations are critical players in ensuring smooth collaboration with the Managed Care organizations. Healthcare organization administration identifies and evaluates risks prevalent in the healthcare industry, labelling them according to severity. The healthcare administration works actively to prevent or reduce any chance of harm to a patient, visitor, employee or employer (Garfield., 2018). Awareness of the threats involved in the healthcare ecosystem and its service delivery is the backbone of identifying risks by a healthcare administrator.
Risk analysis to ensure compliance entails a deep understanding of the already identified risks with factors to consider: various degrees of risks, their causes, and the plans to mitigate or prevent the said risks. For compliance, risk management policies should prioritize the prevention of potential monetary complexities. Guidelines on the safety of patients and employees should be upheld as we look at mitigating risks. Risk management strategies should cover the overall risk of the patients’ spectrum, and medical facilities should share these with the employees for implementation in mitigation of the same.
Regulatory statutes provided to a healthcare organization by of a Managed Care Organization
Regulatory Statutes of MCOs provide a framework from which healthcare organizations benchmark on quality of services and cost-friendly care. These statutes keep monitoring the utilization of healthcare services by clients signing up for the Managed Care plans (Phillips., 2020). They then mandate the healthcare organizations to maintain low costs as they do quality care. This is optimally achieved when there’s avoidance of wastage in healthcare services. These statutes require patients to get authorization before hospitalization or medical assistance.
What MCO responsibilities are relevant to the Patient Protection and Affordable Care Act (ACA) and Center for Medicare and Medicaid Services (CMS) focus on fraud, waste, and abuse laws?
It is a requirement for Managed Care organizations by the ACA and CMS to upgrade and modernize the billing processes to prevent fraud, waste and abuse (Ekin.,2019). Fee-for-service risk provided avenues for fraud, waste and abuse, including denial of services, administrative and logistical barriers for patients, and provisions for substandard care (Walsh., (2021). The responsibility of identifying, investigating and addressing potential fraud and abuse lies on Managed care organizations. Encounter data should also be handed over to compliance desks, where they analyze and detect possible fraud and abuse.
References
Ekin, T. (2019). Statistics and health care fraud: How to save billions. Chapman and Hall/CRC.
Garfield, R., Hinton, E., Cornachione, E., & Hall, C. (2018). Medicaid managed care plans and access to care. Kaiser Fam Found [Internet].
Phillips, S. J. (2020). 32nd Annual APRN Legislative Update: Improving access to high-quality, safe, and effective healthcare. The Nurse Practitioner, 45(1), 28-55.
Walsh, L. A. (2021). Laws, Regulations, and Policies. Introduction to Physical Therapy-E-Book, 62.
Role of Managed Care Organizations Within Health Care and Risk Management Programs.