Risk Management and the Role of Managed Care

Administrative Roles of Healthcare Organizations in line with MCO Standards 

A Managed Care Organization (MCO) provides health services to a group. The administrative roles of healthcare organizations in line with MCO standards include human resources and people management. According to a study by Cogin, Ng, & Lee, human resources administrative role of healthcare organizations in Australia incorporates behavioral control in managing nurses, health workers, and junior doctors. A management role also includes documenting regulations and programs that regulate stakeholders' activities. Healthcare institutions also document the contracts that govern the recruitment of practitioners.

An employment contract of practitioners can also include the terms of termination of employment when a practitioner. The organization's administrative role also encompasses the analysis of service delivery offered to customers. The organization conducts investigations on customer service to identify grievances and problems in delivering services. The Administrative roles also cover the security of organizational and patient information. Managers should implement policies on proper handling of patient information.

The Values Regulatory Statutes MCOs Provide to Healthcare Organizations 

MCO regulatory statues for healthcare organizations cover areas such as risk management and conflict resolution. Joint commission leadership for managing conflict in healthcare organizations mitigates conflicts between management to secure the provision of quality and safe care. This showcases one of the standards documented by the joint commission that is focused on addressing conflict and communication—strategically aligning conflict management approaches that focus on mitigating conflict in management aid in protecting the quality and safety of patient care (Scott & Gerardi, 2019).

Providing healthcare services can bring forth challenges. Risk management in healthcare organizations can be a daunting task. Documenting and assessing healthcare policies creates enormous demands on the part of healthcare managers. Regulations and third-party payer requirements contribute to this problem. Formalized procedures and policies can mitigate such challenges through the promotion of occupational safety, compliance, and provision of safe and high-quality patient care. The MCO policies on risk management facilitate healthcare organizations stakeholders' adherence to recognized professional practices. The regulations promote compliance of managers to the state-mandated statues such as Health Insurance, Profitability, and Accountability (HIPAA) act, conditions of participation, joint commission. Considerations of the regulatory statutes protect both healthcare practitioners from lawsuits and patients for securing private information.

MCO Responsibilities in line with ACA and CMS Focusing on Fraud, Waste, and Abuse Laws 

MCO responsibilities align Medicaid regulations with health coverage programs and take into consideration provisions of the Affordable Care Act (ACA). MCO responsibilities aim to improve transparency, integrity, and accountability of health care organizations (Barsky & Sharma, 2016). IT does so through encouraging regulations against fraud, waste, and abuse. MCOs also tighten standards for submitting, certifying data, and documentation of patient information. Medicaid providers should screen network providers. Medicaid organizations should ensure the safety of patient and company data by vetting network providers. MCOs responsibilities also include responding to investigations and compliance issues relating to allegations of fraud.

The MCO responsibilities in line with the patient protection and affordable care act that protect employees against fraud include the sharing of information. The Anti-kickback statute of 1987 penalizes individuals for refereeing and receiving payment or offers for anything related to Medicaid (Pozgar, 2020). MCOs should share relevant information with healthcare organizations, such as safeguarding patient information from unauthorized personnel. Further, MCO establishes screening procedures for medical suppliers and providers. The MCO also documents licensure checks, criminal and background checks, maintenance and scheduling visits, and database checks. These actions are aimed at preventing patients from fraudulent, waste, and abuse from healthcare organizations. The MCO should take charge of assessing medical suppliers' Medicaid managed care plans. The MCO regulates returns of overpayments of other contractual agreements between healthcare organizations and suppliers. The MCO also mandates that a health organization should suspend medical payments pending investigations where fraudulent activities have happened.

Reference(s)

Barsky, T. & Sharma, R. (2016). Medicaid Managed Care Final Rule: Prevention of Fraud, Waste, and Abuse. https://www.cmhealthlaw.com/2016/08/medicaid-managed-care-final-rule-prevention-of-fraud-waste-and-abuse/

Cogin, J. Ng, J. & Lee, I. (2016). Controlling healthcare professionals: how human resource management influences job attitudes and operational efficiency.  Human resources for health ,  14 (1), 55.

Pozgar, G. D. (2020). Legal and ethical essentials of health care administration. Jones & Bartlett Publishers. 

Scott, C., & Gerardi, D. (2019). A strategic approach for managing conflict in hospitals: responding to the Joint Commission leadership standard.  Part ,  1 , 59-69.