Risk Managment In Health Care

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Risk Management in Healthcare

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Risk Management in Healthcare

This is my reflection on Risk Management in healthcare. Administrative roles of healthcare organizations with relevance to error of risk management policies that guarantee acquiescence with MCO values are inclusive of the development of policies and various programs that are responsible for engaging the stakeholders and the community in decision concerned activities. When it comes to the healthcare organizations, they believe in developing an intricate provider agreement which is inclusive of the standards that are required to appoint practitioners (Ash, 2016). The standards in the contract are also used to specify the termination process when a practitioner does not meet the needs of the set quality criteria.

The coordination of formal and informal complaint plea mechanism is done by the organization as a part of customer service function. This process includes the collection via analysis, investigation and currently recognized problems in the deliverance of the services. When shedding light on the quality managing function comprises of guaranteeing that the set standards of the program, staff and management routine fulfill the MCO set standards via assessment and introduction of continuing developments. The Standard providing activities contain analysis, periodic evaluations and recommending on the area of emphasis for consistent quality enhancement. A general quality valuation and performance development programs are the source which aid in healthcare organization growth.

A classic MCO provides benefits that are the Medicaids requirement. MCO is able to provide such services that cannot be given by free-for-service framework we can take the example of management of disease and the novelty in the care coordination. Further, these services can give benefit to patients. Additionally, MCO can advance the admittance to care for the recipients. Based on evidence, it is stated that is comparison to state-run free for service, managed care as the ability to reduce overall Medicaid program charges, in addition with better patient results. The reason behind regulating private health plans is the assured fact that charges will be adequate to meet their responsibility to the patients. However, there is a risk for MCO. In order to protect the taxpayers, the state Medicaid might opt for setting the rates very low (Houston McGinnis, 2016). This can be driver to MCO going to bankruptcy, or it might boost them restrict the care provided to the patients.

Firstly, what are medical fraud and abuse Making false claims or submitting those false statements to the patients is called fraud. Abuse of Medicare can be explained by a single example the charging of needless medical services or charging too high for supplies and services (Kim et al., 2017). The final rule that has been given by the Medicaid Managed Care strikes to sync Medicaid regulations with additional health coverage programs it also updates the Affordable Care Act healthcare setting. Amongst many goals, there is the objective of reduction of fraud, waste, and abuse. The rule gives various changes that project two kinds of program honesty risks number one being, fraud that has been committed by Medicate management care plans, and the second being, the fraud done by the network providers (Hein Schell, 2018). It also helps in the strengthening of the standards of managed care organization MCO.

When it comes to CMS, to contain a medical fraud, abuse or waste they work with individuals, or law firms to get to the bottom of the things. This is how the MCO responsibilities are in relation with that of the PPACA and CMS guidelines on fraud, abuse, and waste. There are particular standards of conduct that have been articulated to the MCOs commitment to fulfilling all the federal and state standards. Training is given to the MCO employees never to do anything wrongfully. Impactful communication is also given to MCO employees. Prompt action is to be taken when a standard and set criteria are not followed as regards to the MCO agreement.

References

Ash, A. S. (2016). Medical, Social, and Other Determinants of Health Care Costs in MassHealth.

Kim, J. Y., Higgins, T. C., Esposito, D., Hamblin, A. (2017). Integrating health care for high-need medicaid beneficiaries with serious mental illness and chronic physical health conditions at managed care, provider, and consumer levels.Psychiatric rehabilitation journal,40(2), 207.

Hein, E., Post, E., Schell, P. C. (2018). MEDICARE ADVANTAGE PLAN LITIGATION CHALLENGES CMS INTERPRETATION OF 60-DAY OVERPAYMENT RULE.Health Lawyer,30(5).

Houston, R., McGinnis, T. (2016). Program Design Considerations for Medicaid Accountable Care Organizations.Center for Health Care Strategies. February.

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HEALTHCARE AND NURSING

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Running head HEALTHCARE AND NURSING

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