Compliance with Managed Care Organization (MCO) Standards.

Compliance with Managed Care Organization (MCO) Standards.


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. HLT-308V Reflective Analysis: Risk Management and the Role of Managed Care. 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? Please start with an introduction and end with a conclusion.Compliance with Managed Care Organization (MCO) Standards.


Compliance with Managed Care Organization (MCO) Standards

Healthcare organizations are actively involved in the administrative role of implementing risk management regulations and policies, as well as in ensuring adherence to standards set by MCO. The administration in healthcare organizations manages risks through the identification and assessment of risks to prevent harmful events or reduce the risk of harm to patients, workers, and visitors(Graham et al., 2018). Identification of risks in healthcare organizations involves the healthcare providers being aware of the threats within the healthcare environment and services. On the other hand, risk analysis entails developing a concept of the identified risks and classifying them according to the risk levels, root cause, and also the existing procedures to address the risks(Graham et al., 2018).Compliance with Managed Care Organization (MCO) Standards.

Regulatory decrees of the MCO play an important role in enabling healthcare organizations to provide safe and high-quality care, as well as cost-effective care(Graham et al., 2018). Healthcare organizations are obligated by the MCO’s regulatory statutes to provide safe care and ensure healthcare costs are low through close monitoring of the use of healthcare services. By reducing the wasteful use of healthcare costs and preventing avoidable harm, healthcare costs can be controlled. Patients are required by MCOs to obtain authorization from their plans before being admitted to the hospital or being getting specialized care (Graham et al., 2018).Compliance with Managed Care Organization (MCO) Standards.

Risk management policies should aim to prevent possible harmful incidents and prevent likely financial consequences (Simsekler et al., 2018). However, the needs of the patients should be prioritized. Therefore, administration in healthcare organizations should ensure that risk management ensures the safety of patients and staff members as well. Risk management strategies should cover and document all risks relevant to the patients, as well as potential risks to the employees (Simsekler et al., 2018).

MCOs are required by Patient Protection and Affordable Act (ACA) and Center for Medicare and Medicaid Services (CMS) laws to implement comprehensive plans and programs aimed to improve the billing processes in order to detect, identify and prevent any healthcare waste, fraud, or abuse (Adkinson& Chung, 2014). As Cai et al (2020) explain, managed care is normally managed by an intermediary insurer from the primary payer. This brings in possible avenues for fraud, waste, and abuse, including denial of healthcare services, provision of low-quality are, as well as the formation of logistical and administrative barriers for patients. Therefore, MCOs have the duty to identify, investigate, and address the likely frauds, abuse, and wastage. MCOs also have the duty of providing encounter information to the CMs; the information is analyzed in order to detect and identify any form of fraud or abuse.Compliance with Managed Care Organization (MCO) Standards.