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Accreditation is the significant process that Managed Care Organizations (MCOs) need to pass in order to prove their credibility and quality. Both, service providers and customers consider the certification as highly important because it indicates that an organization has attained the standard of quality defined by the accrediting agency. The major Accrediting Agencies in the United States are ABQAURP, NCQA & HEDIS, The Joint Commission, AAAHC & AAAASF and URAC.
Although the criteria for accreditation vary depending on the type of Managed Care Organizations and the accrediting agency, there are certain common factors that are applicable in the review. The Agencies usually consider the “MCO’s quality management program and its impact on operations, at utilization management and how it is carried out, at the MCO’s treatment of members and so forth.” (Kongstvedt., 2003 p. 239).
TRICARE is a managed care option of Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) initiated by Department of Defense (DOD). The service has been delivered through its worldwide Military Health Service System (MHSS). DOD provides Tricare civilian health benefits for military personnel, military retirees, and their dependents through its 11 health service regions. It has also established a new administrative structure to supervise the delivery of health care. (Kongstvedt, 2003 p.1131). Tricare Standard (Fee for Service Program), Tricare Extra (Preferred Provider Option), Tricare Prime (HMO Option), US Family Health Plan, and Tricare Reserve Select (TRS) are some of the major plans of Tricare. As compared to other managed care services in the United States, Tricare offers more steady high quality health care benefits and reduced costs. Tricare service is accessible according to the priority of the beneficiaries as follows; active duty members, family members of the active prime members, retirees and their family members, family
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(Nguyen 2009) The different types of managed health care organizations are listed below. The Health Maintenance Organization (HMO): The HMO is indeed considered to be the first among the managed care organization and these organizations grew at a very rapid pace.
These could be by offering economic incentives to physicians and patients to help them choose less expensive forms of care. It also includes choosing programs for assessing and analyzing the medical necessity of specific services; taking advantage of cost sharing; putting a check on inpatient admissions and the duration of stay; and managing high-cost health care cases correctly.
Current paper focuses on the correlation between the policies related to managed care plans and the activities of managers in health services organizations. Emphasis is given on the issue whether these policies can influence the above-mentioned activities and at what level such interaction could be developed.
He/she is also called primary care physician (PCP). The PCP is usually required for the patients who select healthcare officers from the available managed care network plans of hospitals (Department of Health, 2013). Primarily, managed care is a healthcare procedure that covers cost-containment strategies, risk provision among insurance units, employers and providers, administration and reporting thereon.
That is, whether or not the DRG when treated will result in a positive, or a negative outcome. To be more forthright and simple, if the DRG outcome is death, then intervention, those medical resources rendered in the care and treatment of the DRG, should be
In addition, public policymakers and administrators identified it as an opportunity to minimize the growing expenditures in Medicare as well as Medicaid programs that have been increasingly inclined towards managed
Notably, there existed a series of controversies related with the system of deciding fee for availing services associated with managed care. More importantly, Medicaid rate setting agencies do not face problem with fixing the base rate of the previous year. However, the
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