HLT-308V Reflective Analysis: Risk Management and the Role of Managed Care

HLT-308V Reflective Analysis: Risk Management and the Role of Managed Care

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. 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?

In addition to your textbook, you are required to support your analysis with a minimum of two peer‐reviewed references.

The MCO responsibilities relevant to the Patient Protection and Affordable Act (ACA) and Center for Medicare and Medicaid Services (CMS) focus on fraud, waste and abuse laws

ACA and CMS laws require MCOs to implement comprehensive programs to improve the processes of billing to detect and prevent healthcare waste, abuse, and fraud. According to Thornton et al (2015), managed care as compared to fee-for-service risk is passed to an intermediary insurer from the primary payer, which provides for novel areas for abuse, fraud, and waste, entailing denial of services, provision of substandard care along with the creation of administrative and logistical barriers for patients.  MCOs have the responsibility of identifying, investigating and addressing potential abuse and fraud. Additionally, MCOs responsible for submitting encounter data to the CMs, which is analyzed to detect abuse and fraud. HLT-308V Reflective Analysis: Risk Management and the Role of Managed Care.

References

Alam, A. (2016). Steps in the Process of Risk Management in Healthcare. Journal of Epidemiology and Preventive Medicine, 2(2), 118.

Ness, I.  (2015). Encyclopedia of Interest Groups and Lobbyists in the United States. New York: Routledge.

Thornton, D., Brinkhuis, M., Amrit, C., & Aly, R. Categorizing and Describing the Types of Fraud in Healthcare. Procedia Computer Science, 64(1), 713-720. HLT-308V Reflective Analysis: Risk Management and the Role of Managed Care.

https://www.ncbi.nlm.nih.gov/books/NBK557797/

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