Managed care


Administrativerole of Healthcare organizations on oversight of risk managementpolicies

Managedcare is a health care system that is constituted for theadministration of the cost, utilization as well as the quality ofhealth care systems. It provides a system through which health careorganizations are mandated to provide health care benefits as well asadditional services in a safe, quality-based environment. Therefore,it provides guidelines and standards that healthcare organizationsare supposed to meet in their quest to provide quality, safe healthcare services. Consequently, these organizations developadministrative roles through which they can oversee risk managementpolicies while ensuring that they satisfy the requirement of themanaged care systems (Proctor, 2014).

Oneof the significant administrative positions is the education of thestaff as well as the patients on the new policies to keep them up todate and ensure they understand the ever-changing systems. Also, theadministrations need to adhere to the rules and regulations that thegovernment puts forward, in particular on the issues of healthinsurance, patients’ confidentiality, and billing as well asinsurance fraud. Additionally, the administrations should ensure thatthe patient records are carefully recorded, and all the documentsmaintained in a well-organized manner (Proctor, 2014).

Valueprovided to an organization stemming from regulatory statutes of atypical MCO

Thoughcomplex, healthcare organizations have a primary role in improvingthe health of patients and their communities. However, this agenda isoften lost as a result of conflicts that emerge due to differences inideas, agendas and value systems among the healthcare professionals.A good health care system is the one that achieves its mandate ofproviding healthcare to the people that need it by ensuring that allthe systems are operating well. This is possible where good conflictresolution systems are incorporated in the administrative structure(Proctor, 2014). Hence, an organization emulating typical MCO mustcurb these preventable workplace conflicts amicably. This can be donethrough the development of a regulatory process to addressintimidating and disruptive behaviors. Such a process shouldincorporate input from the major stakeholders in the sector, whichinclude the nursing and medical staff, administrators as well asother employees. Another way of ensuring conflict management has theorganization provide training on collaborative andrelationship-building skills to all the leaders in the system. Theseskills should also entail reporting on unprofessional behavior andconflict resolution (Proctor, 2014).

MCOresponsibilities about PPACA and CMS focus on fraud, waste, andabusive laws

Healthcarefraud, waste, and abuse are major problems in the health sector thatneed to be addressed to ensure sustainable and affordable healthcareprovision to the people. As a result, the government developed thePPACA act to provide guidelines and laws that need to be followed andimplemented to ensure that fraud, waste, and abuse are dealt withaccordingly. It is important to understand that these problems aredealt with swiftly and diligently due to their sensitive nature thatthe ability for them to be transferred from one sector orgeographical location to another (Davis etal.2015).

Therefore,it is the responsibility of every MGO to develop strategies forcombating these healthcare problems. To achieve their mandate, theMGOs have some responsibilities, some of which include scrutiny ofentities and individuals who participate as suppliers and providersin the healthcare system before their enrollment and re-enrollmentinto such programs. The MGOs need to come up with efficient paymentstrategies that are not only responsive but also reasonable on thediversity of the marketplace and medical practice. They should alsoensure that the healthcare providers and suppliers take up practicesthat comply with the program requirement of the health systems.Additionally, the organizations need to ensure that the programs aremonitored vigilantly for any evidence of fraud, waste and abuse, andwhose existence should be dealt with appropriately and punishmentadministered accordingly. It is a belief that when the organizationstake up these responsibilities well, it will promote detections andprevention of such vice in the healthcare system (Davis et al, 2015).


Davis,P. A. et al. (2015). Medicare Provisions in the Patient Protectionand Affordable Care Act

(PPACA):CongressionalResearch Service.pdf

Proctor,L. (2014). Policies and Procedures for Healthcare Organizations: ARisk Management