HLT-308V Reflective Analysis: Risk Management and the Role of Managed Care
A healthcare organization plays a crucial administrative role in executing risk management policies and ensuring compliance with standards established by the managed care organization (MCO). A healthcare organization administrator manages risk by identifying and evaluating risk as a way of lessening harm to patients, visitors, and workers. The administration works proactively as well as reactively to avert incidence or lessen the damages caused by an event. As Alam (2016) indicates, risk identification entails the healthcare professional becoming conscious of the threats in the environment and services. Risk analysis involves developing a…
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.
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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. HLT-308V Reflective Analysis: Risk Management and the Role of Managed Care.
- 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.
| Course Code | Class Code | Assignment Title | Total Points | |||
| HLT-308V | HLT-308V-O500 | Reflective Analysis: Risk Management and the Role of Managed Care | 70.0 | |||
| Criteria | Percentage | 1: Unsatisfactory (0.00%) | 2: Less Than Satisfactory (65.00%) | 3: Satisfactory (75.00%) | 4: Good (85.00%) | 5: Excellent (100.00%) |
| % Scaling | 100.0% | |||||
| Administrative Role of a Health Care Organization in Ensuring Compliance With Managed Care Organization (MCO) Risk Management Standards | 25.0% | An assessment of the administrative role of a health care organization in ensuring compliance with MCO risk management standards is not included. | An assessment of the administrative role of a health care organization in ensuring compliance with MCO risk management standards is partially incorporated, but the information provided is incomplete, inaccurate, or otherwise deficient. | An assessment of the administrative role of a health care organization in ensuring compliance with MCO risk management standards is present, but minimal detail or support is provided for one or more components. | An assessment of the administrative role of a health care organization in ensuring compliance with MCO risk management standards is incorporated in full. The submission encompasses essential details and provides appropriate support. | An assessment of the administrative role of a health care organization in ensuring compliance with MCO risk management standards is comprehensive. The submission further incorporates analysis of supporting evidence insightfully and provides specific examples with relevance. Level of detail is appropriate. |
| Value of MCO Regulatory Statutes to a Health Care Organization | 25.0% | An explanation of the value MCO regulatory statutes provide to a health care organization is not included. | An explanation of the value MCO regulatory statutes provide to a health care organization is partially incorporated, but the information provided is incomplete, inaccurate, or otherwise deficient. | An explanation of the value MCO regulatory statutes provide to a health care organization is present, but minimal detail or support is provided for one or more components. | An explanation of the value MCO regulatory statutes provide to a health care organization is incorporated in full. The submission encompasses essential details and provides appropriate support. | An explanation of the value MCO regulatory statutes provide to a health care organization is present and comprehensive. The submission further incorporates analysis of supporting evidence insightfully and provides specific examples with relevance. Level of detail is appropriate. |
| MCO Responsibilities Relative to ACA and CMS Focus on Fraud, Waste, and Abuse Laws | 25.0% | A description of the MCO responsibilities relative to the ACA and CMS focus on fraud, waste, and abuse laws is not included. | A description of the MCO responsibilities relative to the ACA and CMS focus on fraud, waste, and abuse laws is partially incorporated, but the information provided is incomplete, inaccurate, or otherwise deficient. | A description of the MCO responsibilities relative to the ACA and CMS focus on fraud, waste, and abuse laws is present, but minimal detail or support is provided for one or more components. | A description of the MCO responsibilities relative to the ACA and CMS focus on fraud, waste, and abuse laws is incorporated in full. The submission encompasses essential details and provides appropriate support. | A description of the MCO responsibilities relative to the ACA and CMS focus on fraud, waste, and abuse laws is comprehensive. The submission further incorporates analysis of supporting evidence insightfully and provides specific examples with relevance. Level of detail is appropriate. |
| Thesis Development and Purpose | 5.0% | Paper lacks any discernible overall purpose or organizing claim. | Thesis is insufficiently developed or vague. Purpose is not clear. | Thesis is apparent and appropriate to purpose. | Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose. | Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear. |
| Argument Logic and Construction | 5.0% | Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources. HLT-308V Reflective Analysis: Risk Management and the Role of Managed Care | Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility. | Argument is orderly but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis. | Argument shows logical progression. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative. | Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative. |
| Mechanics of Writing (includes spelling, punctuation, grammar, language use) | 5.0% | Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used. | Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied. | Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed. | Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech. | Writer is clearly in command of standard, written, academic English. |
| Paper Format (use of appropriate style for the major and assignment) | 5.0% | Template is not used appropriately, or documentation format is rarely followed correctly. | Appropriate template is used, but some elements are missing or mistaken. A lack of control with formatting is apparent. | Appropriate template is used. Formatting is correct, although some minor errors may be present. | Appropriate template is fully used. There are virtually no errors in formatting style. | All format elements are correct. |
| Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style) | 5.0% | Sources are not documented. | Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors. | Sources are documented, as appropriate to assignment and style, although some formatting errors may be present. | Sources are documented, as appropriate to assignment and style, and format is mostly correct. | Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error. |
| Total Weightage | 100% | HLT-308V Reflective Analysis: Risk Management and the Role of Managed Care | ||||
Risk Management and the Role of Managed Care
A health care organization’s role in executing risk management policies and ensuring compliance with managed care organization (MCO) standards
A healthcare organization plays a crucial administrative role in executing risk management policies and ensuring compliance with standards established by the managed care organization (MCO). A healthcare organization administrator manages risk by identifying and evaluating risk as a way of lessening harm to patients, visitors, and workers. The administration works proactively as well as reactively to avert incidence or lessen the damages caused by an event. As Alam (2016) indicates, risk identification entails the healthcare professional becoming conscious of the threats in the environment and services. Risk analysis involves developing a comprehension of the identified risks, entailing risk levels, root causes, as well as existing measures that are in place to deal with risks. HLT-308V Reflective Analysis: Risk Management and the Role of Managed Care
The value that regulatory statutes of typical MCO provide to a health care organization
Regulatory statutes of a typical MCO enable a health care organization to deliver quality and cost-effective care. According to Ness (2015), MCO‘s regulatory statutes obligate healthcare organizations to keep the costs of health care down by closely monitoring the utilization of healthcare by enrollees. The notion is that by averting wasteful usage of services, costs can be controlled. MCOs require patients to get authorization from their plans prior to being hospitalized or getting specialized care. HLT-308V Reflective Analysis: Risk Management and the Role of Managed Care
Strategies pertaining to risk management policies affect patients as well as employees and employers. A risk management policy should be aimed at preventing potential monetary consequences, patients’ needs must be a priority. Thus, employers should ensure that before risk management is policy ensures the safety of both patients and employees. Strategies for risk management should cover and document risks that are specific to patients and should, in addition, be accessible to employees (Alam, 2016) HLT-308V Reflective Analysis: Risk Management and the Role of Managed Care.
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.