Course Work On Managed Care Plan

Published: 2021-06-22 00:17:50
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Category: Nursing, Health, Organization, Services, Planning, Health Care, Information

Type of paper: Essay

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How will health care reform impact the small, medium, and large employer’s organization?

Major challenges to managing the enrollment information on a managed care plan.

An inefficient database system. This poses the major challenge for all organizations as the database system used influences the nature of information to be processed. The information system in place is a crucial factor that influences the nature and availability of information regarding to the health care enrollment information. Due to this challenge, the state of Illinois has developed various systems to help to store the data in regard to the particular patient. They include integrated care program and primary care case management program. Information backup systems. It is a normal situation of information loss in a scenario of system breakdown. This poses a major challenge for organizations which have not designed a data backup system in regard to enrollment information. For instance, system failures may lead to loss of crucial patient data, and with no record or backup data files, the recovering of the information may be at stake.

How can managed care plans can monitor and manage claim inventory?

The main crucial factor is an information database and credibility of the source information. The main aim of health care plans is to honour claims from the patients. However, the information in regard to the nature of the claim, as well as the patients' past information forms an important step in making decisions regarding to the claim. For instance, the patient’s claim needs to be fully certified that he or she is fully eligible for the cover. Through information follow up guided by recorded information helps the health care plan to identify the trends of the claims from its insurers. This helps to provide a framework of monitoring the progress and making rational decisions in regard to particular conditions. The process is used by marsh claims, a network of 1500 claim colleagues and risk consultants, located in United States.

Importance of accounting, finance, and underwriting departments in managed health care plans.

The accounting department is used to evaluate the financial performance of the care plan by analyzing the costs and benefits to the plan. The costs in this case mainly involve the claims from insures whereas the benefits mainly are the contributions made. The finance department is used to finance various activities carried out by the plan. It is used to design the funds allocation procedures. Underwriting department is used to oversee the insurance policies issued by the plan to the insurers and make a follow up to identify the payment trend of the premiums. All these departments interact to lead to success of the plan.

How can information technology, data analytics, and reports be used by a health plan or managed care plan to manage costs and quality of care?

Information technology is used as a database system that helps the plan to retrieve information required at a minimal cost. It helps to reduce contingency costs in situations of emergencies. Data analytics help to analyze the data within the health plan thus able to provide credible information to be used by the plan in making its decisions. This works hand in hand with the reports as major reports are made from the data analyzed. The interaction of these elements leads to effective and efficient operation process within the managed care plan which is an important attribute in reducing the overall cost. Efficient operations reduce instances of inefficiency costs, which are associated with ineffective practices.

Purpose of Health Insurance Portability and Accountability Act

The main purpose of HIPAA is to develop minimum federal standards which are meant to safeguard the privacy of individual’s health information. The purpose is supposed to be adopted by various organizations such as health care plans and clearing house, and other health care providers. The rule is further elaborated to cover the rights of an individual which includes right to access and make necessary changes to the information stocked.

The provisions of HIPAA include uses and disclosures for payment, treatment, as well as health care operations, uses and disclosures which require authorization, therapist duties and patients' rights, and uses and duties with neither authorization nor consent. The provisions and purposes are meant to improve the health care conditions in most countries. These conditions need to be followed to make the act feasible in realizing its motives. All the organization mentioned in the act is required to adhere to the set provisions and conditions of the act.

Accreditation

Accreditation can be termed as a process by which an organization or an entity is evaluated, and its set quality standards are established. Therefore, accreditation helps to establish the worthiness of an institution in terms of services provisions. The accreditation process helps in the ranking of the entities or organizations based on the performance and efficiency levels. Accreditation process helps organizations to be effective in their operations thus helping to raise the quality level of the services provided. This helps to reduce the costs incurred by the entity such as cost of inefficiency. Through accreditation, the organization management team tends to be more issue based in order to improve the quality of their services. In a managed health care entities, the quality of services provided serves as the key element of their success. This is an indication that the managing of their operations is basically guided by the set accreditation limits in order to achieve the set goals or objectives. The process entails evaluation of key elements in the operations of the managed care plan in order to meet their satisfaction, as well as the insurer conditions. Institutional accreditation and programmatic accreditation serve best in a managed health care plan. They help to identify the performance of the whole organization and internal functions on the managed care plan.

References

Dyro, J. F. (2004). The Clinical Engineering Handbook (illustrated ed.). New York: Academic Press.
Jacobs, L. R., & Skocpol, T. (2012). Health Care Reform and American Politics: What Everyone Needs to Know (2, revised ed.). London: Oxford University Press.
Kaplin, W. A., & Lee, B. A. (2011). The Law of Higher Education (4 ed.). New York: John Wiley & Sons.
McQuistion, H. L., Sowers, W. E., Ranz, J. M., & Feldman, J. M. (2012). Handbook of Community Psychiatry. New York: Springer.
Sullivan, J. M. (2004). Hipaa: A Practical Guide to the Privacy And Security of Health Data (illustrated ed.). Chicago: American Bar Association.

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