Reflective Analysis: Risk Management and the Role of Managed Care
Reflective Analysis: Risk Management and the Role of Managed Care
Risk management is a core part of quality and safety as it reduces the occurrence of adverse events through deliberate and well-coordinated practices in patient care management and delivery. Managed care organizations play a critical role in care delivery based on their roles as points of care delivery. As such, the management of risks in these entities is essential to guarantee patient safety and quality of care (MACPAC, 2021). The purpose of this reflective analysis paper is to evaluate the role of managed care organizations (MCOs) in healthcare management, especially risk management, through various roles and activities.
Administrative Role of a Healthcare Organization
The administrative role of a healthcare organization in risk management policies is to oversee, monitor, and evaluate their effectiveness in reducing adverse events and improving the quality of care offered. The administrative role in risk management entails setting policies and procedures to manage and identify possible risks and ensure interventions aimed at sustaining and achieving required and best practice standard safety measures for both nurses and patients (Moy et al., 2021). The administrative and risk management roles and responsibilities implore these organizations to uphold compliance measures set by the Managed Care Organization (MCO) framework by not only communicating but also documenting their services (Heaton & Tadi, 2023). They also ensure that their services meet MCOs goals of reducing healthcare costs through preventive measures, financial provisions, and treatment guidelines aimed at improving patient care quality. For example, an MCO standard for healthcare administrators is to manage Medicaid medical costs and expenses caused by preventable events like infections and falls.
Value of MCO Regulatory Statutes
Regulatory statutes of a typical MCO offer significant value to a healthcare organization as MCOs set high standards that the entities should comply with to get reimbursement from CMS. Managed Care Organizations were designed to deliver quality and cost-effective care to patients. Therefore, these statutes focus on ensuring that patients get the quality care they deserve at an affordable cost. Again, healthcare organizations benefit from MCO statutes as they implement measures to monitor and prevent possible fraud and wasteful practices.
These statutes compel health care organizations to develop and implement risk management strategies and policies that raise awareness among stakeholders and ensure compliance with the programs. Through these strategies, the organizations offer safe and quality practice settings for providers and enhance patient care and safety (Heaton & Tadi, 2023). Healthcare organization’s administrators use these strategies to manage high-risk situations, develop and improve educational training materials, and maintain, monitor, and evaluate patient scenarios that require problem-solving skills and conflict resolution approaches.
MCO Responsibilities
The Patient Protection and Affordable Care Act (PPACA) and the Centers for Medicare and Medicaid Services (CMS) have comprehensive approaches and requirements for fraud, waste, and abuse prevention. As such, managed care organizations (MCOs) help attain the desired controls and implementation of relevant strategies to reduce and prevent fraud, waste, and abuse of healthcare resources (MACPAC, 2021). Therefore, MCO responsibilities relevant to these laws and policies include detecting and reporting fraud, implementing compliance programs, and cooperating with regulatory entities by providing necessary data and participating in fraud prevention measures and initiatives.
The collaboration entails the deployment of advanced healthcare technologies like electronic health records (EHRs) to streamline data sharing and lower administrative costs (Chen et al., 2020). MCOs actively monitor and detect possible fraudulent activities like billing for services that a facility does not provide or the creation of “ghost patients and facilities to get reimbursement. As such, MCOs engage in regular audits and investigations to identify such practices and incidents in healthcare facilities. MCOs establish compliance programs that educate and raise awareness among stakeholders, like healthcare providers and patients, concerning legal requirements and ethical standards. These strategies help prevent fraud, waste, and abuse of the processes and resources. As such, by fulfilling these responsibilities, MCOs help ascertain that the healthcare system operates ethically and efficiently to meet patient needs at a reduced cost of care.
Culture of Reporting and Transparency
A culture of reporting and transparency is critical to attaining patient safety and quality care for healthcare organizations, as it reduces risks emanating from activities, including preventable adverse events like infections. Lindhout and Reniers (2022) observe that transparency is a core aspect of patient safety in healthcare settings. Therefore, healthcare facilities and providers can develop a reporting and transparency culture when they implement certain strategies. These include establishing clear policies and procedures, having blameless and non-punitive reporting channels and requirements, training employees on procedures and interventions to cultivate transparency, and providing leadership support and accountability. More fundamentally, healthcare entities should develop a safety and collaborative culture that encourages sharing and reporting as opposed to blaming and victimization of those reporting any adverse events or errors (Fukami, 2024). Finally, open communication through establishing avenues for feedback, celebrating achievements, and recognizing nurses’ contributions builds trust and a shared approach.
Conclusion
Managed care organizations (MCOs) play a critical role in risk management for healthcare organizations and providers based on their roles and responsibilities. Administrative staff in healthcare organizations should ensure their facilities comply with set regulations and comply with ACA and CMS requirements to prevent fraud, waste, and abuse of healthcare resources. Effective strategies enhance a reporting and transparent culture that is critical to the attainment of patient safety and quality outcomes.
References
Chen, Z. X., Hohmann, L., Banjara, B., Zhao, Y., Diggs, K., & Westrick, S. C. (2020).
Recommendations to protect patients and health care practices from Medicare and
Medicaid fraud. Journal of the American Pharmacists Association, 60(6): e60-e65.
DOI: 10.1016/j.japh.2020.05.011
Fukami, T. (2024). Enhancing healthcare accountability for administrators: Fostering
transparency for patient safety and quality enhancement. Cureus, 16(8).
DOI: 10.7759/cureus.66007
Lindhout, P., & Reniers, G. (2022). The “Transparency for Safety” triangle: Developing a smart
transparency framework to achieve a safety learning community. International Journal
of environmental research and public health, 19(19): 12037.
DOI: 10.3390/ijerph191912037
Heaton, J. & Tadi, P. (2023 March 6). Managed Care Organization (MCO). StatPearls [Internet].
https://www.ncbi.nlm.nih.gov/books/NBK557797/
Medicaid and CHIP Payment and Access Commission (MACPAC) (2021 January 12). Managed
care program integrity.
Moy, H.P., Giardino, A. P., & Varacallo, M. A. (2023 July 25). Accountable Care Organization.
https://www.ncbi.nlm.nih.gov/books/NBK448136/
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Assessment Traits
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Assessment Description
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 750-1,000-word response that addresses the following:
- Explain what a health care organization’s administrative role is in executing risk management policies and ensuring compliance with managed care organization (MCO) standards.
- Explain what value the regulatory statutes of a typical MCO provide to a health care organization and include strategies pertaining to policies such as conflict resolution and risk management that affect patients and families as well as employees and employers.
- Explain what MCO responsibilities relevant to the Patient Protection and Affordable Care Act (ACA) and Centers for Medicare and Medicaid Services (CMS) focus on fraud, waste, and abuse laws.
- Identify strategies that can be implemented for developing a culture of reporting and transparency.
In addition to your textbook, you are required to support your analysis with at least three credible health-related resources.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.