Reflective analysis managed care organization role in risk management

Reflective analysis managed care organization role in risk management

The managed care organization (MCO) refers to an establishment that helps to integrate the role of administration and insurance, as well as the deliverance of care (Caswell & Long, 2015). It can include the physical hospital, management services organization, independent practice organizations as well as the third-party administrators. Managed care organizations have the responsibility to provide care services through a specified provider framework.

The role of the administrative healthcare organizations that regard toan oversight of risk policies and management while also make sure there is compliance with MCO standards is not only to ratify programs but even systems that allows the public and stakeholders to get involved in making decisions (Caswell & Long, 2015). It is the organization of MCO that regulates the recruitment of practitioners through the process of generating a detailed provider agreement. It is also important to realize that the healthcare organization oversees the appeal processes regarding client’s grievances. It also does the work of managing performance, programs the standards of staff within the organization to meet the requirements of MCO through the introduction and assessment of any existing development within the organization.

The typical regulatory statutes of the MCO provide appropriately for the risk as well a conflict management processes that relate to the provider and patient relationships (Kavaler & Alexander, 2014). The created prepaid care services and the fee for the services insurance entail two of the most important funding and delivery plans of the MCO in the healthcare system. The delivery and financing services integrate the four main units such as personal consumer, service provider, insurer as well as the insurance purchaser (Kavaler & Alexander, 2014). The fee for service insurance that necessitates the client to choose their favorite provider is vital in enhancing the patient-provider relationship hence helping to minimize any potential conflicts (Kavaler & Alexander, 2014). The prepaid care approach through the maintenance of healthcare has a complex substructure that allows the regulation of the cost and quality by way of assuming the cost of risk incurred by the client.

MCO through the managed care strategy has an important part to play in the inquiry, detection as well as deterrence of any supposed abuse, fraud and waste (Mendelson, Goldberg, & McConnell, 2016). The MCO should promote prevention through the screening of workers and network providers to create their presence in Medicaid programs. On the detection, MCO should do a detailed analysis of its schemes concerning fraud, abuse, and waste. The MCO must also investigate waste, fraud, and violence founded on the agreement that exists between managed care proposal and state Medicaid bodies.

The administrative responsibility of the care organization is to help establish strategies that incorporate stakeholders in making decisions (Mendelson, Goldberg, & McConnell, 2016). The MCO regulatory decrees have specific plans that help to enhance the management of risks and conflicts about healthcare delivery to the patients. Though, the MCOs must conform to the patient protection and affordable care Act for the provision of adequate healthcare.



Caswell, K. J., & Long, S. K. (2015). The expanding role of managed care in the Medicaid program: implications for health care access, use, and expenditures for nonelderly adults. The Journal of Health Care Organization, Provision, and Financing52, 0046958015575524.

Kavaler, F., & Alexander, R. S. (2014). Risk management in healthcare institutions: Limiting liability and enhancing care. Jones & Bartlett Learning.

Mendelson, A., Goldberg, B., & McConnell, K. J. (2016). New rules for Medicaid managed care–Do they undermine payment reform?. Healthcare (Amsterdam, Netherlands)4(4), 274.