The assignment assesses competency 5 Investigate the key org

The assignment assesses competency 5. Investigate the key organizational functions of administering managed care programs, including contracting, reimbursement systems, utilization review, quality assurance, and plan management, 12. Critique cost and quality control mechanisms within managed care environments.

Directions: As employers look to control health care costs, MCOs have implemented utilization review protocols to ensure the right care is provided to patients at the right time. At the same time, employers, regulatory agencies and accreditation organizations have increased their expectations that the quality of care increases for patients receiving care through the MCO.

In no less than 4 and no more than 6 pages, write a paper that addresses the following:

• Define the key elements in utilization review and quality management.
• Compare and contrast these two functions and how they have changed over time.
• What role does each of these play in managed care? Be sure to think about this from employers who offer coverage to their employees; to regulatory agencies who provide oversight; and to private organizations that conduct external reviews.
• In your opinion, do these functions add value to managed care? Support your opinions with examples and your research.
• Cite references used in writing your paper.

Solution

Solution:

The goal and structure of utilization review and quality management is for informing the quality of services. It is delivered to the patients and it aims to increase the probability of effective clinical outcome. The goal is for utilizing the important elements of every program.

Perspective review is related to assuring the unique utilization of hospitals, providers, case management and other services. Prospective review is also related to continually assessing and improving as access to care and medical care. The important element of oreahthiruzatuin review is proposing surgeries and essential health care services in patient and outpatient. It reflects important element for eliminating the surgery that is unnecessary and helps in avoiding the redundant examination costs. Integrity reflects honesty, morals and values with click to facts and expectations if the customers. Trust is an important key. The functions add to a manged care by adding to organization, control and quality measurement. It helps to achieve the goals of the purchaser effectively. The strategies of managed care are altered effectively. There is influence on the delivery of public and privately reimbursed mental health it reflects specific arrangements for practitioners for furnishing key sets of health care services.