...Achieving and Maintaining Accreditation in Managed Care Name: Institution: Devry Table of Contents Introduction………………………………………………………………………………………3 Background……………………………………………………………………………………….3 Importance of accreditation…….………………………...………………………………………3 Accreditation Bodies……………………………………………………………………………...4 Literature review………………….…………………………………………………………….....4 Challenges that are experienced in achieving and maintaining accreditation…………………..…5 The role of the URAC as an Accreditation Body………………………………………………....5 How the URAC accredits healthcare institutions….........................................................................6 Quality assessment and control solutions in accreditation ……………………………………......8 Implementation of quality improvement and accreditation solutions…………………………......9 Justification…………………………………….…………………………………………………10 Summary and conclusion……………………….…...……………………………………………10 References ………………………………………………………………………………………..11 Achieving and Maintaining Accreditation in Managed Care Managed healthcare organizations and professionals encounter numerous challenges on a yearly basis in the course of offering services, whereas the state, stakeholders, and clients (patients) expect to be reassured that bodies that render managed healthcare services are well equipped to meet their demands. Accreditation is, therefore, a detailed evaluation process through which an independent professional...
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...A Marketing Plan for an Imaginary Managed Care Organization Executive Summary and Situation Analysis Working for the Managed Care Organization of America, the ultimate goal would be to ensure cooperation in the understanding, agreement, and commitment between all divisions and units. One of the problems at the Managed Care Organization of America is that the healthcare professionals are put in a position where they are inhibited in their involvement over the communication and networking systems between the Nursing Administration, the head of each nursing unit or the RN or LVN in charge, and the certified nursing aids. This executive summary takes a brief look at designing and developing a contract process program that integrates cooperation and communication systems between the Nursing Administration, the head of each nursing unit or the RN or LVN in charge, and the certified nursing aids. Another challenge for the Managed Care Organization of America is the unclear policies in the Hospital Equipment Management Program. This executive summary offers a proposal whereby the healthcare professionals would develop and monitor a two-way communication channel and incorporate it into the Hospital Equipment Management Program, hold related workshops that can be attended by the Director of Hospital Operations and the division managers, build a cooperation team that unites operational goals and develop systems that evaluate whether these operational goals are being met and implemented...
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...Abstract The purpose of this paper is to identify a strategic management plan of a healthcare organization. My selection is a false managed care organization called GreenLine that is based on a well-known health insurance company that provides a variety of health care plans . In this paper the following will be discussed: factors affecting managed healthcare organizations, strategic initiatives, financial information, and organizational structure. Socioeconomic Factors Socioeconomic status (SES) is an economic and sociological combined total measure of a person's work experience and of an individual's or family’s economic and social position in relation to others, based on income, education, and occupation. Socioeconomic status is typically broken into three categories: low, middle, and high SES. Income has been shown to have a heavy effect on whether families will purchase health care insurance and it’s been proven that people with lower incomes tend to have more problems physically and mentally. Most diagnosis seen are respiratory viruses, arthritis, coronary disease, and schizophrenia. Lower socioeconomic status is also been said to link to stress. Legislative Factors Most recently there has been the ongoing implementation of Patient Protection and Affordable Care Act in the United States which affects all managed healthcare companies and businesses with more than 50 employees. Patient Protection and Affordable Care Act consists of a combination of measures to control...
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...U7A1: MBA 663-8: Health Insurance and Managed Care LEGAL AND ETHICAL ISSUES Legal and Ethical Issues The current landscape of the healthcare industry changes rapidly with new rules and regulations, placing many healthcare insurance and managed care organizations in jeopardy of litigation because of legal and ethical issues. Controversy surrounds the healthcare industry because of the decisions made by managed care organizations regarding patient treatment and payment to providers. The following examines the legal and ethical issues surrounding the everchanging healthcare insurance and managed care organizations. Managed Care Conflict The problem facing managed care organizations and health insurance is the inherent conflict with their goal of cost containment by reducing service utilization, with the healthcare delivery system that places the patient’s health first (Kongstvedt, 2013). According to Saunier (2011), the definition of managed care is: 2 Processes or techniques used by any entity that delivers, administers and / or assumes risk for health services in order to control or influence the quality, accessibility, utilization, costs and prices, or outcomes of such services provided to a defined population. (Saunier, 2011, p. 22) Saunier (2011) describes the purpose of these organizations that manage care is the control of costs by “implementing aggressive cost containment mechanisms” (p. 22). The main goals of the healthcare delivery system include: 1. The provider...
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...purpose of managed care is for administration to have access, control, and quality over health care services within a particular population of enrollees that are covered (University of Washington, 1998). The method of managed care involves a group of skills which persuades the clinical behavior of patients and or providers, done by bringing together the delivery and payment of health care. By using managed care, healthcare administrators are able to develop ways to effectively run healthcare systems by allocating money for departments that are in dire need of funds. Also by implementing measurements that monitor employees work habits, such as how often a nurse should check on patients, how many times a day medications are given, how often bedding is changed, updating charts, and etc. Changing the quality of care, based on customer service, the collaboration of other staff employees, and improved work ethics among staff all has and will continue to affect healthcare. Managed care organizations and doctors use managed care contracts to create the broadest applications possible within the healthcare industry (AMA, 2005). Physician networks, professional corporations, group practices, and individual doctors are the ones who normally enter such contracts. When dealing with managed care contracts the provision of enrollees of medical services are arranged through directly administering or offering of one or more health benefit products or plans within an organization (AMA, 2005)...
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...The brain child of managed care was adopted in the 1973 to counter the high cost of healthcare provisions. The sole purpose of managed care was to provide effective and quality medical care to patients at reduced cost. It entailed choosing a doctor that would have been responsible in providing the medical facilities to patients with minimal charges since the companies providing such services had a contract with the organization. It was first targeted to provide medication to the timber workers, the miners and the residents residing in the rural who were unable to get affordable healthcare. The managed care has then been consumed and accepted by the American citizen as well by the providers. It is a common practice that has been promoted across...
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...MEMORANDUM ON MANAGED CARE TO: Dr. Forney Fleming and the Class of Fall’14 for American Healthcare System FROM: Iyappan Somasundaram DATE: September 10, 2014 RE: Managed Care, Markets and Rationing Briefing Paper MANAGED CARE: An organized way to deliver healthcare services by efficiently utilizing healthcare resources to provide quality patient care. Managed care principles have been used for over 100 years in the U.S. The major goals of managed care include improving quality and accessibility of health care, improving outcomes and overall quality of life for patients and containing costs. The growth of managed care in the U.S. was spurred by the enactment of the Health Maintenance Organization Act of 1973. The organizations that use the above techniques or provide them are called “MCO” or “Managed Care Organizations”. Managed Care organizations are broadly classified into two categories viz. HMO, PPO & POS. During the last quarter of the 20th century, HMOs emerged as an important alternative to traditional medical indemnity insurance plans, and largely supplanted them. This was largely known as the “managed care revolution”. HMOs have had a profound effect on every aspect of the practice of medicine-professional, scientific, social, economic, and legal. HMO (Healthcare Maintenance Organizations): HMOs are comprehensive health care delivery systems that offers a wide range of healthcare services through a network of providers who agree to supply services...
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...EXAM To purchase this visit following link: http://www.activitymode.com/product/hsm-544-final-exam/ Contact us at: SUPPORT@ACTIVITYMODE.COM HSM 544 Final Exam Study Guide The final examination for this course is comprehensive, and it emphasizes key concepts from all weeks of the course. 1. Identify the major tasks of economics and discuss why they are important. What are their roles in organization management? 2. Identify and discuss the factors that influence the demand, in turn healthcare economics. What factor do you believe has the greatest impact on healthcare economics and why? 3. Discuss the role of all parties (patient, providers, and payers) to contain costs. Analyse the impact of cost-containment efforts on the rising cost of healthcare. 4. What are the primary steps in a production function analysis? How would you apply these steps in a healthcare organization? 5. Discuss the connection between redistribution and social insurance 6. How does the role of non-profit healthcare organizations differ from profit healthcare organizations? 7. Discuss the concept of managed care. Why was it created? What were its goals? Have these goals changed? Has it worked? How it can be improved? Pick one of the previous questions for your initial post; all of them will be discussed throughout the week. Wishing you all success on your final exam! Activity mode aims to provide quality study notes and tutorials to the students of HSM 544 Final Exam in order to ace their...
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...In the past five years, there have been three major trends in health care services in the United States: patient-centered care, managed care, and the collaboration of health care systems with insurance providers. The United States is made up of diverse groups of people who all have different preferences, morals, values, and traditions (Carr, 2017). Patient-centered care is healthcare professionals, healthcare systems, families, and patients working together in the meaningful and valuable interest of the patient (Carr, 2017). Effective communication is among the necessary skills and attitudes healthcare professionals must acquire to meet the needs of patients and improve overall quality and safety in system-wide healthcare delivery (Carr, 2017)....
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...Managed Care is bad for healthcare providers. Managed Care is a huge part of health care today, but is it the answer in controlling health care costs? Managed care plans were originally credited in the 1940’s as non-profit organizations and it wasn’t until the 1970’s and 1980’s when healthcare costs soared that employers saw this as an alternative approach. But are Managed Care Organizations (MCOs) the best solution for healthcare providers? Many say, “no.” According the American Medical Association, “late payment of claims by managed care organizations (MCOs) and other payers is a common problem for many physicians in a wide range of practice settings, and combating this problem is a priority for the AMA.” There is also a heavy administrative burden on physicians and their staff who often spend excessive time on the phone with MCO’s pursuing unpaid and overdue claims, it is not unheard of for some claims to be outstanding for six months or more. “Managed care plans receive a predetermined amount of money per member, regardless of the service.” (Baker, 2011, p. 35). A clinical perspective of why Managed care is bad for healthcare providers at times is MCOs across the country have taken control of medical decision making by blurring the definition of medical necessity-a clinical determination with covered services-a business determination. At the same time, MCOs specifically disclaim any responsibility for medical decision making and seek to place all liability...
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...International Dr. Leequan Ray Managed Health Care is debated on a number of aspects; nature and origin of managed care, the notion of the death of managed care and the current state of managed care in the U.S. health care system. Anyone in America, who’s used healthcare insurance through their employer, experienced managed care at some point. What is managed care and how does it affect us? The Health Maintenance Organization (HMO) ACT of 1973 required employers with more than 25 employees to offer federally certified HMO options along with indemnity insurance upon request. With the HMO ACT of 1973, employers needed them more than ever. HMOs had to instantly find a way to provide quality care at the lowest possible cost to the employer, so they engineered techniques that became known as managed care. Managed care is loosely defined as a mixture of techniques intended to reduce the cost of providing health benefits in order to improve the quality of care for a predetermined population. The intent is to decrease unnecessary cost through a multitude of mechanisms which include offering economic incentives for physicians and patients to select less costly forms of care, reviewing the medical necessity of specific services, increasing cost sharing, controlling inpatients admissions, length of stay and contracting with health care providers. Early on, managed care seemed to be the answer to the escalating cost of U.S. healthcare, but patients were very limited in their...
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...of Contents…………………………………………………………………………………..2 Introduction to Managed Care and the Pros………………………………………….3-4 • Types of managed care • How managed care is governed Cons of Managed Care…………………………………………………………………………..4-5 • Why is there a need for managed care Conclusion……………………………………………………………………………………………..5 References……………………………………………………………………………………………..6 Health insurance plans that contract with health care providers and medical facilities to provide care for members at reduced costs are called managed care plans. There are three different types of managed care plans, and can benefit individuals in different ways depending on the coverage options they are looking for. Like a lot of different things, managed care can have positives and negatives. Managed care is where health insurance companies have contracts with health care providers and facilities to provide care to patients at a reduced price. These providers make up the plan's network. How much of your care the plan will pay for depends on the network's rules and if the provider is in that specific network. There are three different types of managed care; HMO, PPO, and POS. HMO is a health maintenance organization and this is where they usually only pay for care within that network. Some insurance companies like Summa, Anthem Blue Cross Blue Shield, and Medical Mutual offer HMO plans. A PPO is a preferred provider organization which is where they usually pay more if you get care within the...
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...page 1 1. (TCO A). You are a healthcare consultant hired by the Midwest Healthcare System to assist them in developing their organization's strategic plan that will shape the development of a comprehensive network of services for their community. The organization provides the usual array of inpatient services expected in a moderate-sized community hospital. A local nursing home and retirement community is for sale, and the organization is considering the purchase of that agency. There is a regional hospital that is trying to establish a statewide hospital network. There is a local county health department that provides some clinic services, primarily for the uninsured. You’ve been asked to give a presentation to the board of directors on options for restructuring their local delivery of healthcare services. The hospital's president has asked you to focus your presentation on the elements of a comprehensive delivery system and to highlight innovative methods to restructure the hospital. The presentation will lay out the requirements of an integrated healthcare delivery system. (Points : 25) 2. (TCO B). You are the newly hired Vice President of Human Resources for the Bayside Regional Health System. You have the responsibility for all of the usual human resources functions, including retention plans, the training and development function, and the recruitment process. In addition, you have the additional departments of volunteers and the...
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...Roles and Responsibilities in National Healthcare Reforms Every healthcare environment such as hospitals, nursing homes, ambulatory care centers, nurses have always had the closest relationship with patients and their families. Nurses assess, monitor, provide care and meet patients’ needs, relay information between physicians and patients, advocate for patients and families. Nurses have not being involved in making significant policy decisions to high quality patient care but as our country focuses on healthcare reform which will guarantee that all American have right to excellent and reasonably priced health care, nurses’ roles and responsibilities are expected to change from patient care to taking responsibilities on many new health care imperatives. According to the report of IOM, nurses should be associates with doctors and healthcare professionals in restructuring healthcare in our nation. Nurses’ responsibilities will become more prominent in continuity of care, accountable care organizations (ACO), medical homes, and nurse-managed health clinics. The purpose of this speech is to enlighten nurses about the changes that will be anticipated in their roles as healthcare professionals as these reforms take place in the healthcare industry. Continuity of care is a system of patient care integration that follows patients over time through comprehensive arrays of health services across all levels of care. It allows patients’ care to be managed efficiently from primary physician...
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...Final Exam Health Service Systems Week 8 – Final 1. (TCO A) You are the newly hired Chief Knowledge Officer (CKO) for a mid-size hospital in a semiurban area of the country. Your first task is to develop the organization’s strategic plan that will shape the development of a comprehensive network of services for their community. The organization provides the usual array of inpatient services expected in a moderate-sized community hospital. A local nursing home and retirement community is for sale, and the organization is considering the purchase of that agency. Several physician practices are also interested in alliances with the hospital. There is a local county health department that provides some clinic services, primarily for the uninsured. You’ve been asked to give a presentation to the board of directors on options to restructure the local delivery of healthcare services. The hospital’s president has asked you to focus your presentation on the common elements a comprehensive delivery system attempts to accomplish and to highlight innovative methods of restructuring. The presentation will lay out the requirements of an integrated healthcare delivery system. (Points: 25) 2. (TCO B) You are the newly-hired Vice President of Human Resources for the Bayside Community Health System. You’ve been on the job for just 3 months and have considerable experience in human resource functions. You have responsibility for all of the usual human resources functions, including the recruitment...
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