Reflective Analysis Essay: Risk Management and the Role of Managed Care Reflective Analysis Essay: 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. ? Reflect on and evaluate the role that the managed care organization (MCO) plays in todays health care environment by developing a 250?500-word response that addresses the following: What is a health care organizations 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. 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. Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required. 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. Refer to the?LopesWrite Technical Support articles?for assistance. ORDER INSTRUCTION-COMPLIANT PAPERS HERE Attempt Start Date:?24-Aug-2020 at 12:00:00 AM Due Date:?30-Aug-2020 at 11:59:59 PM ? Study Materials Legal and Ethical Essentials of Health Care Administration ? Read Chapters 18, 19, and 26 in?Legal and Ethical Essentials of Health Care Administration. URL: https://www.gcumedia.com/digital-resources/jones-and-bartlett/2013/legal-and-ethical-essentials-of-health-care-administration_2e.php chapter 10: EMTALA and Managed Care ? Read ?Chapter 10: EMTALA and Managed Care,? by Moffat, from?EMTALA Answer Book?(2015). URL: https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=99912645&site=ehost-live&scope=site Network Strategies: Finding a Better Path Through Coordinated Care ? Read ?Network Strategies: Finding a Better Path Through Coordinated Care,? by Horn, from?Benefits Magazine?(2015). URL: https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=102649158&site=ehost-live&scope=site ? College of Nursing and Health Care Professionals: Do We Know What Our Future Is? ? Watch the video ?College of Nursing and Health Care Professionals: Do We Know What Our Future Is?? URL: http://lc.gcumedia.com/zwebassets/courseMaterialPages/nur508_healthcare-reform-video-series-v1.1.php EMTALA: A Shifting Landscape ? View the presentation ?EMTALA: A Shifting Landscape,? located on the American Bar Association (ABA) website. URL: https://www.americanbar.org/content/dam/aba/administrative/healthlaw/EMTALA_4_10_18.authcheckdam.pdf Assessing Changes to Medicaid Managed Care Regulations: Facilitating Integration of Physical and Behavioral Health Care ? Read ?Assessing Changes to Medicaid Managed Care Regulations: Facilitating Integration of Physical and Behavioral Health Care,? by Edwards (2017), located on The Commonwealth Fund website. URL: https://www.commonwealthfund.org/publications/issue-briefs/2017/oct/assessing-changes-medicaid-managed-care-regulations-facilitating The Health Care Fraud and Abuse Control Program Protects Consumers and Taxpayers by Combating Health Care Fraud ? Read ?The Health Care Fraud and Abuse Control Program Protects Consumers and Taxpayers by Combating Health Care Fraud,? from the CMS Newsroom (2016), located on the U.S. Centers for Medicare and Medicaid Services (CMS) website. URL: https://www.cms.gov/newsroom/fact-sheets/health-care-fraud-and-abuse-control-program-protects-consumers-and-taxpayers-combating-health-care Reflective Analysis Essay: Risk Management and the Role of Managed Care Order Now

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Risk Management and the Role of Managed Care

Introduction

Managed care is an approach to health care delivery that attempts to improve the efficiency and effectiveness of organizations that deliver it. It can be defined as a system of coordinated relationships between health care providers, patients, payers, and other providers involved in the management of personal health services. A managed-care plan may give one or more organizations responsibility for all or part of the process from managing health benefits to delivering care. Managed care thus differs from previous approaches in which medical facilities have provided their own services

Background into risk management and managed care

Risk management is a way of reducing the negative consequences of risk by identifying and managing those risks. The goal is to minimize the number of negative outcomes that occur, as well as their cost.

Risk management can be used to improve quality and reduce costs through the development and implementation of a plan with specific goals for each patient, such as reducing hospitalizations or decreasing readmissions after surgery. Managed care plans are often organized by an insurance company (for example, Blue Cross/Blue Shield), which provides services directly or through contracted providers such as hospitals or doctors’ offices

Insurance

In the United States, insurance is a contract between two parties. One party pays the other in exchange for coverage and reimbursement from an event that might occur (the risk). Insurers make money by charging premiums to policyholders who want to protect themselves against financial risks. Insurance companies are regulated by states and federal governments; they must follow specific guidelines set out in law or regulation as well as adhere to certain standards on consumer protection measures, such as fraud prevention.

Medicare and Medicaid

Medicare and Medicaid are government-funded health insurance programs for people over 65, people with disabilities, and some people with low incomes. Medicare is for those who are age 65 or older (or disabled) and have worked long enough to qualify for it; Medicaid is a joint federal/state program that provides medical care to all poor Americans at no cost to them, regardless of their age or income level.

Medicare offers benefits through its own website (www.medicare.gov), but you can also apply directly through your state’s Office of Disability Determination Services (ODDS) if you live in one of these states: California; Colorado; Connecticut; Delaware; District of Columbia; Florida; Hawaii (all counties); Idaho (counties only); Illinois—City & County Only ; Indiana—Counties Only ; Iowa–Counties Only ; Kansas–Counties Only ; Kentucky–Counties Only ; Louisiana–All Counties Except Ouachita Parish Anywhere Outside Parish Limits And Evangeline Parish Anywhere Outside Parish Limits : Maine–All Counties Except Aroostook County And Washington County Anywhere Outside Statewide Boundaries And Kennebec River Basin Area Lying West Of Interstate 95 From Wahconah Lake To Rangeley Lakeshore Including Towns On Either Side That Do Not Fall Within The Scope Of This Boundary Such As Bar Harbor Beach Area In Hancock County On Lake Sebago At Its Southernmost Point Beresford Point On Moosehead Lake Near Brooks Pond Road As It Applies From The Route 26 Bridges East Bound Butterfield Overpass Or Route 495 Bridge Downstream From Exit 4 Off I-93 In Lincoln Tunnel Area Between Portland Culver City Glendale Los Angeles Mission Hills Palmdale Pasadena San Fernando Valley Santa Clarita Valley San Fernando Valley Santa Clarita Valley San Fernando Valley Santa Clarita Valley

Health maintenance organizations (HMOs)

Most health plans are HMOs. This means that the care you receive is managed by your primary care physician, who coordinates with other doctors and specialists in your network of providers to ensure that you have all the services necessary for a healthy lifestyle. The takeaway from this is simple: if you want someone else to manage your health care, make sure they’re qualified!

You can also use this article as an opportunity to learn more about managed care itself—it’s not just a way of managing costs; it’s also an effective way of keeping people healthier longer than they would otherwise be able to afford without assistance from their insurer (or employer).

Preferred provider organizations (PPOs)

A PPO is a type of managed care plan that contracts with doctors and hospitals to provide services at a reduced cost. PPOs typically offer lower premiums than traditional health insurance, which means you pay less for your medical expenses if you use them instead of going through an insurance company’s network.

PPOs are usually used by employers to provide health insurance for employees who work in certain jobs or industries, such as dentists or nurses (for example). This makes sense since those people would have different needs than someone who works at McDonald’s or Wal-Mart; they might need more expensive treatments like brain surgery but wouldn’t necessarily need dental care every now and then, so it makes sense for companies like these ones to use their own networks rather than having everyone buy into one big plan across all industries where everyone has similar needs–it would save money by eliminating unnecessary overhead costs associated with running multiple plans at once!

Managed care increases the availability of care while reducing costs.

Managed care is a system of health care that uses a network of health care providers to deliver medical services to enrollees. In managed care plans, patients do not pay for their individual physician visits or hospitalizations; instead, they pay either an annual deductible or monthly premiums based on their income and other factors.

Prepaid managed-care plans typically have lower monthly premiums than traditional indemnity plans. However, there can be additional costs associated with these plans because they require members to go through the process of enrolling in them (which may take months) before being eligible for coverage during the year – and once enrolled in such a plan you are required by law to remain continuously covered until your policy expires at midnight on December 31st unless you choose otherwise under certain circumstances such as becoming unemployed due injuries sustained while performing work duties during off-hours hours (i..e., 3pm-6am).

Conclusion

The use of managed care has been a major factor in the trend toward lower costs and improved quality. The degree to which managed care is used in health care varies across settings and regions, but there is evidence that it can lower costs and improve outcomes.

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