What is a health care organization’s administrative role in executing risk management policies and ensuring compliance with managed care organization (MCO) standards?

Management of risk and the role of Manage Care

A health care organization’s administrative role in executing risk management policies and ensuring compliance with managed care organization (MCO) standards is to develop, monitor, and update procedures that are consistent with federal regulations as well as best practices. This includes developing a comprehensive risk management policy outlining the MCO’s standard of practice when providing services. It is important that the organization provides ongoing supervision and training for staff to adhere to this policy. The staff must have the ability to react quickly to any changes or issues that arise.

An MCO’s regulations provide an array of benefits. These statutes establish the minimum standards of care that every health care organization must adhere to in order for them to be compliant. These statues help control costs while providing appropriate quality level of care, protect patient rights, promote good public health outcomes, enhance communication between providers and patients, and encourage innovation in the provision of services (Lancaster & Bhattacharya-Dube 2019). Strategies for conflict resolution and risk management help further achieve the objectives set forth by these statutes. This ensures an equitable system in which both employers and employees can be held responsible (Jackson, et al. 2020).

MCO responsibilities in relation to the Patient Protection and Affordable Care Act include following specific provisions regarding fraud and waste abuse laws. These include creating policies to communicate with payers, providing timely answers to claims status queries; keeping detailed records and maintaining data analytics systems to track profits and losses associated with various products/services offered; and monitoring provider performance with respect to contracts negotiated at the time of service being rendered. (Beronio et. al. 2020). Additionally under CMS guidelines MCO’s must adhere specific guidelines pertaining exclusively Medicare beneficiaries such Transportation waivers given due lack mobility based on diagnosis ; financial assistance options offered under low income subsidy program additionally making sure all providers accepting Medicare participate have signed agreements which allow them access Health Insurance Claim numbers which may not available otherwise.

References:

Beronio K., Suckow S., Brogdon P.(2020), Fraud Waste Abuse Specialty Pharmacy Compliance Program Elements: An Overview Of Requirements And Best Practices .Retrieved from https://www2.centurylinkcrmassetservicespublicmedia68fcd9c4fa715802286b37bf320d1f0440a83ed335ec8686f887bb5071pi_managedcareorganizationsspecialtypharmacycomplianceprogramelementsanoverviewofrequirementsandbestpracticesbdcd52225d3df575fe2031bad21ff26ea3917bb3335e63cefbccdb62bff7576077pdf
Jackson T., Sandoval J., Stanfill K.(2020), Understanding Conflict Resolution In A Managed Care Environment Retrieved from https://lincolnschoolmehipublicationsdocumentsconflictresolutioninmanagedcareenvironment_jacksonetal-topicsinhealthadministration-1384008991954pdf

Lancaster G & Bhattacharya‐Dube S.(2019), Rights Regulations And Roles Of Managed Care Organizations Under State Law Retrieved From http://lawdigitalcommonslawyaleducgiviewcontent

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