5 2 Milestone Three Final Project 10082017.docx

Enforce disciplinary standards through well published

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Enforce disciplinary standards through well published guidelines, to make sure all employees understand the implications. From what I know, the managed care environment it’s all about the quality and affordable healthcare to its members. If I was the running the negotiations, I would consider the payer and provider relationship. Does the provider have a long standing relationship with the payer or is this contract just going to be a one-time negotiation. Is the compensation fair for services that will be provided? Is the provider getting a good rate? More importantly do your payer homework and make sure you have the payer knowledge you need to bring to the table to negotiate. There are several roles within a healthcare organization when it comes to Managed Care. Primary Care Physician, aka the Gatekeeper, the primary care physician. Case Manager, who finds appropriate physicians for the patients. Prescription Benefit Manager, they provide the prescription side of the health plan. Ideally Managed Care Contracts can lead to better patient satisfaction. However, managed care can be extremely complex. Based upon Harrington (2016), Managed Care, the cost 4
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management, the contract management and the quality of care all can have significant impacts on a healthcare organization. Corporate Compliance programs, if in place will help to ensure proper billing and coding compliancy. To ensure regulations and ethical standards within the organization a Code of Conduct should be established. It states your commitment to ethical and the accurate coding in accordance with all of the regulatory requirements. In addition, the AHIMA's Standards of Ethical Coding should be included within your coding code of conduct as well. References: 5
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Harrington, M. K. (2016). Health care finance and the mechanics of insurance and reimbursement. Burlington, MA: Jones & Bartlett Learning. AHIMA, Code of Ethics Medline Plus, Managed Care 6
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  • Fall '16
  • Jeniffer Walter
  • Revenue Cycle Management, revenue cycle process

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Christopher Reinemann
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