Reflective Analysis: MCO Role in Risk Management and Compliance

This report analyzes the role of Managed Care Organizations (MCOs) in healthcare, focusing on their administrative roles in risk management, compliance with standards, and regulatory statutes. It examines how MCOs manage and reduce risks, including their indemnity insurance objectives and risk-sharing mechanisms. The report explores the value of regulatory statutes, such as liability statutes, and strategies for conflict resolution and risk management affecting patients, employees, and employers. Furthermore, it addresses MCO responsibilities concerning the Patient Protection and Affordable Care Act (ACA) and the Center for Medicare and Medicaid Services (CMS), specifically in combating fraud, waste, and abuse within healthcare programs. The conclusion highlights the importance of MCOs in maintaining healthcare standards and compliances for effective risk and conflict management.

Title: Managed Care Organizations
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Introduction
Managed Care Organizations have the approach for the administrative benefits that
are being used for optimizing the patient care (McConnell, 2016). It has the standards and
compliances which are appropriate for risk management and conflict resolution. Here, the
response is based on the administrative role played by the managed care organizations in
meeting the compliances, standards and regulatory statutes.
Standards for MCO and Risk Management
The administrative role of managed care organization is comprehensive in the risk
management policies or the meeting of the compliances and the standards. The physicians
who practice in the managed care organization have the provisions that manage and reduce
the risk (Howard, Bernell, Yoon, Luck, & Ranit, 2015). The organization has the basic
objective of indemnity insurance that can provide the protection against the risk evolved in
the patient’s life. Also, there are certain standards and compliances that can are met by these
organizations in order to act in the favour of the patient. These are brought up by the risk-
sharing mechanism for every stakeholder. Managed care organization make the health plans
and also there are certain obligations of MCO which is determined by the contractual
agreement.
Regulatory Statutes of MCO
The regulatory of statutes of typical MCO have value into the healthcare organization.
These statutes are the liability statutes that declares that the managed care organization is not
liable for the wrongful actions or the personal injury being caused under the organization.
Further, there are certain strategies which are built by the managed care organization for
conflict resolution and as well as risk management for the patients and the staff members as
well. Further, MCO follow the ethical guidelines for the conflict resolution and make an
effective decision and reducing the risk involved (Govind , 2012). Further, MCO specifically
accounts for mediating bioethics conflicts under the healthcare setting that resolves the
conflicts through the assistance of third party. Moreover, the state and federal regulations can
be effectively used for the handling of disagreements.

MCO Responsibilities to Affordable Care Act (ACA)
Combating fraud, waste and abuse in health care is the main motive of the managed
care organization in order to avoid the federal expenditures. As per Patient Protection and
Affordable Care Act (ACA) provides the provisions regarding the fraud, waste and abuse in
the combating of the Medicare and Medicaid (Medicare Advocacy, 2011). The responsibility
of MCO is to follow the ACA guidelines and making more balanced approach for the
provisions pertaining to ACA. Further, MCO has the responsibility towards the Centre for
Medicare and Medicaid Services (CMS) for the administration of managed healthcare
programs that can lead to the improved health and eliminate the instances of the fraud and
abuse.
Conclusion
To conclude, it can be said that managed care organizations have the certain standards
and compliances that are being used for the risk management and conflict management. Here,
the response is based on the regulatory MCO and their responsibilities in terms of ACA and
Centres for Medicare and Medicaid Services (CMS).

References
Govind , S. (2012, June 11). Medicaid managed care organization oversight. Retrieved
February 1, 2020, from AICPA Store:
https://www.aicpastore.com/Content/media/PRODUCER_CONTENT/Newsletters/
Articles_2012/CPA/Jun/OrganizationOversight.jsp
Howard, S., Bernell, S., Yoon, J., Luck, J., & Ranit, C. (2015). Oregon's experiment in health
care delivery and payment reform: coordinated care organizations replacing managed
care. Journal of health politics, policy and law, 40(1), 245-255.
McConnell, K. (2016). Oregon’s Medicaid coordinated care organizations. Jama, 315(9),
869-870.
Medicare Advocacy. (2011, May 26). Combating Fraud, Waste and Abuse in Health Care.
Retrieved February 1, 2020, from Center for Medicare Advocacy:
https://www.medicareadvocacy.org/combating-fraud-waste-and-abuse-in-health-care/