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Assessment Description
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 250â€500-word response that addresses the following:
What is a health care organization\’s administrative role in executing risk management policies and ensuring compliance with managed care organization (MCO) standards?
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.
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?
In addition to your textbook, you are required to support your analysis with a minimum of two peerâ€reviewed references.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
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Managed Care and Risk Management in Health Care
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Managed Care and Risk Management in Health Care
The health care organizations’ administrative role in executing risk management policies and ensuring compliance with managed care organization (MCO) standards
Healthcare organizations play an important administrative role in implementing the risk management policy to promote adherence to MCO standards. For instance, the health care organization administrator identifies and evaluates risks to reduce harm and injuries to patients, workers, and visitors (Huang et al., 2018). The administrators design a health care risk management plan that incorporates processes, systems, and protocols that promote MCO standards.
The value the regulatory statutes of a typical MCO provide to a health care organization
Regulatory statutes of a typically managed care organization (MCO) allow healthcare organizations to provide quality and affordable care services. The regulatory statute compels healthcare organizations to maintain a low cost of health care services by keeping a close eye on how the enrollee makes use of health care (Heaton &Tadi, 2022). The cost of care can be controlled by avoiding wasteful usage of resources. Strategies regarding conflict resolution and risk management policies have a significant influence on patients, employees, and employers. These strategies protect and ensure the safety of patients and employees (Mosadeghrad & Mojbafan, 2019). They also ensure a productive employee-employer relationship.
MCO responsibilities that are relevant to the Patient Protection and Affordable Care Act (ACA) and the Center for Medicare and Medicaid Services (CMS)
MCO has some responsibilities that tend to be of relevance to ACA and CMS. For instance, CMS and ACA direct MCOs to establish programs to reduce fraud, waste, and abuse of law (Shachar, & Curfman, 2020). Therefore, MCO is granted the responsibility to investigate, identify, and address issues related to abuse of the law, fraud, and wastage. Furthermore, MCOs have the responsibility of submitting encounter information to CMS for analysis and detection of fraud, abuse of the law, or wastage.
References
Huang, C., Iqbal, U., & Li, Y. (2018). Healthcare improvement measures in risk management and patient satisfaction. International Journal for Quality in Health Care, 30(1), 1-1. https://doi.org/10.1093/intqhc/mzx192
Heaton, J., &Tadi, P. (2022). Managed Care Organization. https://www.ncbi.nlm.nih.gov/books/NBK557797/
Mosadeghrad, A. M., & Mojbafan, A. (2019). Conflict and conflict management in hospitals. International journal of health care quality assurance, Vol. 32 No. 3, pp. 550-561. https://doi.org/10.1108/IJHCQA-09-2017-0165
Shachar, C., & Curfman, G. (2020). Reconsidering Health Care Fraud and Abuse Laws. JAMA, 324(17), 1735. https://doi.org/10.1001/jama.2020.19795