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Reflective Analysis-Risk Management and the Role of Managed Care

Reflective Analysis-Risk Management and the Role of Managed Care

Health care organization’s administrative role in executing risk management policies and ensuring compliance with managed care organization (MCO) standards

Risk management is a responsibility that involves numerous internal stakeholders in the managed care setting. Among the stakeholders are the healthcare administrators. Their main role in the execution of risk management policies and ensuring compliance is the appointment of a risk manager. Qualified healthcare risk managers act on behalf of the administration by conducting assessments, developing and implementing, as well as monitoring the risk management plans that they create. The risk managers also represent the administration in the identification of hazards, evaluation of the potential risks, training of staff in the management of the risks and hazards, and ensuring that patients and the workforce are exposed to minimal harm. Their role in representing the administration is proactive and reactive in nature (Mohiuddin, 2019). Therefore, the administration ensures that patient and work safety are prioritized through the risk managers.

What value do the regulatory statutes of a typical MCO provide to a health care organization?

Based on the regulatory statutes of managed care organizations, a health care organization gains a reputation as a quality care provider who is affordable, reliable, and easily accessible. The healthcare organization also attains a proactive capability to manage its costs and monitor the services that physicians offer regularly. The expenditure management ability results from the need to create a list of services that each provider should furnish and stick by. The process of assessing and monitoring quality consistently creates a positive brand of a health care organization. In addition, such organizations tend to prioritize preventive care, which they can easily control in terms of cost. The provision of primary care to the patient population distinguishes a facility from its competitors in the health promotion process.

Consider how strategies pertaining to policies such as conflict resolution and risk management affect patients as well as employees and employers.

Risk management policies have a direct effect on employees and patients. Both coexist within the same environment. The employee’s role in promoting patient safety is top among other responsibilities (Parand, 2014). If an organization is unable to manage the present risks effectively, they expose both parties to unsafe environments, increase the likelihood for litigations, which are agreeable by the Organization Safety and Health Act (OSHA) policies, risk revocation of accreditation, and undermine all efforts that are dedicated towards the promotion of safety (Classen & Kilbridge, 2002). Similarly, conflict resolution policies tend to have a negative effect on employees and employers. If the two parties lack effective frameworks and mechanisms to resolve conflict, the quality of interactions and work tends to sway towards the negative side. Thus, the administrators should ensure that all three parties’ concerns and needs are addressed through a selection of effective conflict resolution and risk management strategies.

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?

Screening providers prior to enrollment plays a key role in preventing fraud, waste, and abuse. MCOs are required to screen the chosen providers thoroughly and continuously assess or monitor the sustenance of quality (Centers for Medicare & Medicaid Services, 2016). The screening process allows managed care organizations to specify the list of services that a provider should furnish. This eliminates loopholes for abuse and wastage through unnecessary utilization of additional services. Furthermore, constant monitoring of physicians’ services and costs sets a precedent that promotes the integrity of health care providers as it pertains to patients’ sessions, medication, and medical procedures. Essentially, most of the loopholes that have allowed fraud, waste, and abuse in the past are sealed in managed care organizations.

References

Centers for Medicare & Medicaid Services. (2016). The Health Care Fraud and Abuse Control Program Protects Consumers and Taxpayers by Combating Health Care Fraud. Retrieved from https://www.cms.gov/newsroom/fact-sheets/health-care-fraud-and-abuse-control-program-protects-consumers-and-taxpayers-combating-health-care

Classen, D. C., & Kilbridge, P. M. (2002). The Roles and Responsibility of Physicians to Improve Patient Safety within Health Care Delivery Systems. Journal of the Association of American Medical Colleges, 77(10), 963-972.

Mohiuddin, A. K. (2019). Medication Risk Management. Innov Pharm., 10(1). doi:10.24926/iip.v10i1.1647

Parand, A. (2014). The role of hospital managers in quality and patient safety: a systematic review. BMJ Open, 4(9). doi:10.1136/bmjopen-2014-005055

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Question 


Reflective Analysis-Risk Management and the Role of Managed Care

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.

Reflective Analysis-Risk Management and the Role of Managed Care

Reflective Analysis-Risk Management and the Role of Managed Care

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:

  • 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 peer‐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.

See attached .Rubric_Print_Format_(4)

RUBRIC
Maximum Points: 70.0

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