Challenges faced by MCOs regarding price variations and ways of overcoming these challenges
Challenges
Utilization management acts as one of the most complex financial balancing act that managed care organizations (MCOs) try to utilize in an effort to manage health care costs and create value for future health care services (Bailit & Sennett, 1992). However, managing cost through utilization management concept creates price variations that pose major challenges to MCOs. One of the major challenges faced by MCOs regarding price variation is its diverse nature. The use of utilization management in MCOs has gained a lot of demand making it difficult to make a general conclusion on certain variations. Price variations linked to providers become hard to manage especially when the MCO management does not know whether the variation functions freely, operates under a prepaid health plan, or is integrated into insurance. Second, the lack of regulatory oversight affects the ability of MCOs to manage utilization management through price variations. The limited regulatory restrictions increase risks that affect the form of care provided to the patient.
How to deal with challenges
Any organization that plans to use utilization management must assess the current impact of price variation plans available and research on future changes to overcome some challenges that affect the delivery of care. First, the MCO should acquire appropriate links with parties associated with providing medical benefits to patients to avoid the challenge of diversity and ensure all patients’ records describe their respective medical cover information. Second, managers of MCOs together with government health officials should develop regulatory policies for controlling health costs. According to Fox and kongstvedt (2015), standard measures have been created aimed at evaluating health plans to prevent ongoing regulatory mistrust in both private and public organizations.
Processes of institutional utilization management
Creating the institutional utilization management program follows three processes names prospective, congruent, and retrospective. The prospective process takes place whenever required procedures and practices require a review. The second process, congruent, takes place when a review requires the screening of medical information and when the institution offers a scheduled timeline for delivering the medical care plan. The last process, retrospective, allows the institution to review and analyze original client’s data for medical purposes, appropriateness, and delivery of quality care (Paramount Care, Inc. Paramount Care of Michigan, Inc. & Paramount Insurance Company Paramount Advantage, 2013).
Role of utilization management nurse
Utilization management nurse working in the present nursing practice plays the role of ensuring the care offered to the patient is appropriate and recommendable. The utilization management nurse must familiarize himself/herself with different types of insurances offered to managed care organizations, their rules, benefits, and challenges. The knowledge of various insurances allows the nurse to determine the best level of care that the patient should receive based on the condition and the benefits offered by the insurance. Additionally, utilization management nurses collaborate with specialists, physicians, and treatment team to record patient's respond and ensure the patient's documents explain the type of care provided. Moreover, the nurse must deliver patient's information on managed care to insurance providers within the specified deadline (Llewellyn, 2014).
Disease management versus case management
Disease management refers to the type of care targeting patients with a major health care problem and requires a qualified standard set of needs while case management refers to the care that targets patients with high health risks because of living in diverse environments posing health, social, and economic problems. Disease management and case management have a major similarity because they both aim at preventing or controlling health problems. On the other hand, the two differ because whereas disease management concentrates on one specific type of health problem, case management focuses on a wide range of health problems in a community.
The Care continuum Alliance
Purpose: To promote population health management
The Commission of Case Manager Certification
Purpose: A national accreditation organization whose main objective is to certify case managers in the case management industry.
Standards for certification/membership: An individual must have current, active, and unrestricted licensure in human services or health discipline that allow the person to conduct an independent assessment. Alternatively, an individual candidate must have a graduate degree in nursing, social work or any health-related course and promotes psychosocial, physical, and vocational training (Commission for Case Manager Certification, n.d).
References
Bailit, H. L., & Sennett, C. (1992). Utilization management as a cost-containment
strategy. Health Care Financing Review, 1991(Suppl), 87–93.
Commission for Case Manager Certification. (n.d). About case management. CCMC. Retrieved
Jan. 21 2017, from https://ccmcertification.org/about-us/about-case-management
Fox, P. D., and Kongstyvedt, P. R. (2015). A history of managed health care and health
insurance in the United States. In Kongstvedt, P. R. (2016). Health insurance and managed care: What they are and how they work. Burlington, MA: Jones & Bartlett Learning.
Llewellyn, A. (2014, May 20). Nursing Beyond the Bedside: Utilization Review Nurses.
NurseTogether. Retrieved Jan. 21 2017, from http://www.nursetogether.com/nursing-beyond-bedside-utilization-review-nurses
Paramount Care, Inc. Paramount Care of Michigan, Inc. & Paramount Insurance Company
Paramount Advantage. (2013, June 11). Utilization management program description. Retrieved Jan 21, 2017, from https://www.paramounthealthcare.com/documents/provider/Utilization-Mgt-Program.pdf
