Nursing Assignment: Reflective Analysis of Risk Management and MCOs

This nursing assignment delves into the critical aspects of risk management within the healthcare landscape, with a specific focus on the influence and responsibilities of Managed Care Organizations (MCOs). The report examines the administrative roles healthcare organizations undertake to execute risk management policies and ensure compliance with MCO standards, highlighting the significance of supplier contracts, complaint mechanisms, and quality management functions. It further explores the value derived from MCO regulatory statutes, particularly concerning Medicaid programs and value-based arrangements. The assignment also analyzes the impact of conflict and risk management strategies on both patients and healthcare professionals, emphasizing the importance of fostering strong relationships and reducing patient anxiety. Finally, it outlines the MCO responsibilities related to the Patient Protection and Affordable Care Act (ACA) and the Center for Medicare and Medicaid Services (CMS), specifically concerning fraud, waste, and abuse laws, and the maintenance of program integrity.

Running head: NURSING ASSIGNMENT
RISK MANAGEMENT IN HEALTHCARE SETTING
Name of the Student
Name of the University
Author note

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NURSING ASSIGNMENT
Administrative roles performed by healthcare organizations for the accomplishment
of the risk management strategies in safeguarding acquiescence with MCO standards is
by designing policies and platforms involving public and stakeholders in decision focused
actions (Alley et al., 2016). Health care organization cultivates an intricate supplier
contract, which includes principles that need to be used in assigning practitioners. The
contract also specifies the termination method when the specialists do not meet eminence
principles.
The organization synchronizes informal and formal complaints engaging mechanism
as a part of the customer facility function. It includes the collection of data through
investigations, presentation and analyzing problems acknowledged in distributing
services (Garfield et al., 2018). Quality management functions include safeguarding the
standards of staff, performance management and the program fulfilling with the MCO
(Managed care organization) standard by calculating and familiarizing ongoing
enhancements. Setting activity standard includes periodic appraisals, enquiry and
approvals in specific areas for continuous enhancement in quality.
The regulatory statues of MCO provide to healthcare are the additional services
provided through contracted benefits of arrangements with Medicaid agencies. These
value-based arrangements require to predict financial risk for the health service cost such
as payment capitation from the MCO’s. MCOs delivers Medicaid programs health
services the beneficiary facilities that can decrease the program cost and better utilization
of management in health services. Development in the health plan, quality and outcomes
are the main purpose of the Medicaid managed care. Few states in the US have
implemented a wide initiative range in order to initiate and coordinate care that is beyond
traditional managed care system (Betancourt et al., 2016). The initiative taken helps in

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improving population care with complex and chronic care conditions that are aligning
with payment along with performance goals and accountability for the better quality of
life.
Conflict causes tension in the workplace and the outcome is always poor. Conflict
management helps in the enhancement for a better outcome. Conflict and risk
management are important so that employees can concentrate on their work to help the
patients. It helps in building a stronger relationship between patient and nurse as well as
employer and employee. Risk and conflict management also help patient for better than
and reduction in their tension and worries.
MCO responsibilities that are related to Patient protection and Affordable Care Act
are to place new responsibility and monitor care plans. It enrols and screens services that
are of benefit to the patient as well as state services (Ginter, Duncan & Swayne, 2018).
The second responsibility is to stop defiance with medical loss and recoveries of
overpayments. It prevents the wastage of money. The third rule is to maintain the
integrity of the programme. The program coordinates frauds causes and payments.

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References
Alley, D. E., Asomugha, C. N., Conway, P. H., & Sanghavi, D. M. (2016). Accountable
health communities—addressing social needs through Medicare and Medicaid. N Engl J
Med, 374(1), 8-11.
Betancourt, J. R., Green, A. R., Carrillo, J. E., & Owusu Ananeh-Firempong, I. I. (2016).
Defining cultural competence: a practical framework for addressing racial/ethnic
disparities in health and health care. Public health reports.
Garfield, R., Hinton, E., Cornachione, E., & Hall, C. (2018). Medicaid Managed Care
Plans and Access to Care. Washington: Kaiser Family Foundation.
Ginter, P. M., Duncan, W. J., & Swayne, L. E. (2018). The strategic management of
health care organizations. John Wiley & Sons.