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Monday, August 18, 2014
  Clinical Accuracy Spoken Here  

Population Health:
MCO Rules and Regs

An MCO is a health insurance organization with administrative control over health care services provided to its membership. To ensure MCO solvency and member access to quality care, MCOs are heavily regulated at both the federal and state levels. An MCO may be required to be:

  • Licensed in each state in which it conducts business
  • Subject to requirements of various state departments

States may require MCOs to maintain accreditation from such agencies as URAC or the National Committee for Quality Assurance (NCQA) in order to be granted the required state licensure.

[Reference: Population Health, Module A, Prior Authorization]

  Excellence in Case Mgmt  

Population Health: The Role of UM

With the advent of Managed Care Organizations (MCOs), the emphasis changed from policing to coordination, with facilitation and education of members and providers through utilization management (UM).

The role of a UM program is to focus on providing members with 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]

  Improving Patient Care...  

Population Health: Key Elements

The MCO (CM) reviewer must consider four key elements when making determinations:

  • Is the patient an eligible member of the MCO, and if so is the MCO the primary payer?
  • Does the member's benefit allow the requested treatment?
  • Are there network limitations that must be met?
  • Does the clinical documentation provided meet medical necessity for the procedure or level of care?
The initial step is always to confirm that the patient is an eligible member of the MCO. If it is determined and confirmed that the patient is not, there are no next steps.

[Reference: Population Health, Module A, Prior Authorization]


Tom RasmussenTom Rasmussen
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