Managed care organizations (MCOs) have become integral to the modern healthcare environment. These organizations provide various services, including health insurance, network management, and utilization management. The administrative role of healthcare organizations in executing risk management policies and ensuring compliance with MCO standards involves several key functions.
Firstly, healthcare organizations must ensure that their policies and procedures align with MCO standards. This involves working closely with MCOs to understand their requirements and expectations. Healthcare organizations must develop policies and procedures consistent with MCO standards and guidelines (Joynt Maddox et al., 2019). For example, MCOs may have specific requirements regarding network provider credentialing, utilization management, and claims processing. Healthcare organizations must ensure their staff members are trained and equipped to comply with these standards.
Secondly, healthcare organizations must monitor and evaluate their compliance with MCO standards. This involves establishing a system for identifying and reporting potential compliance issues, such as data breaches, billing errors, and quality-of-care concerns (Hartmann-Boyce et al., 2020). Healthcare organizations should also establish an internal review process for addressing and resolving compliance issues. This process should involve conducting root cause analyses and implementing corrective actions.
Healthcare organizations can improve their compliance with MCO standards by implementing risk management policies (Lasater et al., 2019). Risk management is a systematic process that involves identifying, assessing, and mitigating risks that may affect an organization’s operations. Healthcare organizations can use risk management to identify potential compliance issues and take steps to prevent or minimize them (Joynt Maddox et al., 2019). For example, healthcare organizations can use risk management to identify areas where there is a high risk of medical errors or patient harm. By taking proactive steps to address these risks, healthcare organizations can improve their compliance with MCO standards and provide safer, more effective care to their patients.
The regulatory statutes of a typical MCO provide several benefits to healthcare organizations. For example, these statutes provide a framework for ensuring that healthcare services are delivered in a safe, effective, and efficient manner. They also provide guidance on how to address conflicts and risks that may arise between patients, employees, and employers. Additionally, these statutes promote transparency, accountability, and quality improvement in the healthcare industry.
The Patient Protection and Affordable Care Act (ACA) and the Center for Medicare and Medicaid Services (CMS) have several responsibilities relevant to MCOs regarding fraud, waste, and abuse laws (Lasater et al., 2019). The ACA established the Fraud and Abuse Control Program, which is designed to prevent and detect fraud, waste, and abuse in federal healthcare programs (Joynt Maddox et al., 2019). The CMS also has a range of responsibilities related to fraud and abuse prevention, including monitoring claims and billing patterns, conducting audits and investigations, and imposing penalties for noncompliance.
Healthcare organizations can benefit from working closely with MCOs to ensure compliance with these regulatory statutes. By working together, healthcare organizations and MCOs can develop policies and procedures that align with regulatory requirements and promote quality improvement in the healthcare industry (Hartmann-Boyce et al., 2020). For example, healthcare organizations can collaborate with MCOs to develop strategies to prevent fraud, waste, and abuse. These strategies may involve implementing fraud detection software, conducting regular audits and investigations, and training staff members on fraud prevention best practices.
In addition to regulatory compliance, MCOs also play a role in managing healthcare costs. One way that MCOs do this is by using utilization management techniques. Utilization management involves reviewing and approving healthcare services to ensure they are necessary and appropriate for the patient’s condition (Hartmann-Boyce et al., 2020). By using utilization management, MCOs can help prevent unnecessary healthcare spending and promote cost-effective care (Lasater et al., 2019). Healthcare organizations can work with MCOs to ensure that they use utilization management techniques consistent with regulatory requirements and promote high-quality care.
In conclusion, MCOs play a crucial role in today’s healthcare environment. Healthcare organizations must work closely with MCOs to ensure compliance with their standards and regulations, develop risk management policies, and promote quality improvement in the healthcare industry. Regulatory statutes guide how to address conflicts and risks that may arise between patients, employees, and employers, while also promoting transparency, accountability, and quality improvement. By working together, healthcare organizations and MCOs can improve patient outcomes, reduce costs, and ensure that healthcare services are delivered safely, effectively, and efficiently.
References
Hartmann-Boyce, J., Morris, E., Goyder, C., Kinton, J., Perring, J., Nunan, D., Mahtani, K., Buse, J. B., Del Prato, S., Ji, L., Roussel, R., & Khunti, K. (2020). Diabetes and COVID-19: Risks, Management, and Learnings From Other National Disasters. Diabetes Care, 43(8), 1695–1703. Web.
Joynt Maddox, K. E., Reidhead, M., Hu, J., Kind, A. J. H., Zaslavsky, A. M., Nagasako, E. M., & Nerenz, D. R. (2019). Adjusting for social risk factors impacts performance and penalties in the hospital readmissions reduction program. Health Services Research, 54(2), 327–336. Web.
Lasater, K. B., Jarrín, O. F., Aiken, L. H., McHugh, M. D., Sloane, D. M., & Smith, H. L. (2019). A Methodology For Studying Organizational Performance. Medical Care, 57(9), 742–749. Web.