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Monday, May 20, 2013
  Clinical Accuracy Spoken Here  

Population Health:
MCOs Emphasize Coordination

An MCO is a health insurance organization with administrative control over health care services provided to its membership. The intention is to reduce costs while assuring quality of care by eliminating redundant services and providing care at the appropriate level.

The emphasis of Managed Care Organizations (MCOs) is coordination, with facilitation and education of members and providers through utilization management (UM).

The role of a UM program is to focus on access to quality care and monitoring the appropriate utilization of services through:

  • Early case identification
  • Communication
  • Proactive intervention

[Reference: Population Health, Module A, Prior Authorization]
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  Excellence in Case Mgmt  

Population Health:
MCO CM Program Goals

In a Managed Care Organization (MCO), the managed care case manager's (MCO CM) role mirrors that of the hospital case manager (HCM), with the added charge of providing those considerations within the constraints of the contractual benefits available to each MCO member.

The critical MCO program components directed at meeting the MCO CM program goals are:

  • Inpatient and outpatient prior authorization
  • Concurrent review of ongoing treatment
  • Discharge/transition planning

Each of these components requires both clinical and benefit considerations, and they are applicable in a variety of MCO utilization management models.

[Reference: Population Health, Module A, Prior Authorization]
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  Improving Patient Care...  

Population Health:
Determining LOS

During the initial conversation with the HCM, it is important to determine what system each CM is utilizing in order to expedite concurrent reviews.

Not all inpatient facilities employ experienced case managers, and smaller facilities may not utilize criteria from any vendor to determine length of stay appropriateness.

The MCO can provide an outline to facility reviewers as a template for reviews for any charge nurse or nurse providing care to the patient to use.

[Reference: Population Health, Module B, Concurrent Reviews]
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