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Managed Care Organization (MCO) Article Summary

Managed Care Organization (MCO) Article Summary

Sample Answer 

Managed Care Organization (MCO) Article Summary

Provide a summary of the article you selected. Include the key reimbursement issue addressed

I chose the article by Holtrop, Luo, and Alexanders titled: Inadequate Reimbursement for Care Management to Primary Care Offices. The article focuses on care management in primary care and its reimbursement impact. Notably, care management can be effective in primary care services to patients with chronic illnesses. They can help in improving their health, but there are several challenges they can face in identifying revenue that needs to be paid for. The study explored the direct reimbursement’s impact on care management’s provision in an organization for primary care physicians. The study revealed that care management direct reimbursement covered just 21 percent of the total costs. There were variations in reimbursement based on the background of the care manager, diagnosis of the patients, indication for the patient visit, and the insurer. The various barriers that were revealed to gaining reimbursement were the patient resistance to co-pay, the hesitation of physicians to bill for visits under care management due to fear of the patient receiving the hospital bill, differential policies in reimbursement by insurers, as well as the general failure in many cases of reimbursement for care management.

How they would impact the NP in a collaborative practice versus an independent practice.

The challenges in reimbursement can affect a physician organization in obtaining direct reimbursement that is enough to cover the care management costs. It can also affect the perspective of primary care as regards financial barriers to the delivery of care management. In this sense, an NP in a collaborative practice will also be affected in the same way (Henkel & Maryland, 2015). This is because an NP, as well as clinical leaders and primary care operations, are the main decision-makers who determine whether care management is availed to patients. Even when the care management is effective cost-wise from the society or payer’s perspective, if it fails to maintain neutrality in the budget or demonstrate revenue that is appreciable to the practice organization or practice, it still poses a challenge in implementation.

As an independently practicing NP, the economic credentialing will pressure the NP to consider the financial factors when making treatment recommendations, conflicting with the patient advocacy professional ethics. This is because the NP will constantly be worried that in treating individuals ‘cheaply’ they will be retained in the network of managed care as opposed to those favoring better outcomes from longer-term treatment plans who are at risk of exclusion. Thus, the question of ethical patient care will be a constant bother to the NP when practicing independently under an MCO (Friedrich & Lindeke, 2015).

Discuss an ethical or legal implication(s) associated with your article.

Medication costs take large attention in the healthcare financial burden. These represent major care barriers for many patients. On the one hand, insured patients bear many significant costs, such as coverage and service costs. On the other hand, an insured patient will most likely face numerous out-of-pocket payments, including copayments for treatment and visits, deductibles, and monthly premiums. Patients whose income is modest may drop their coverage or look for alternative plans. When there is an increase in various cost-sharing levels, such as copayments, it can reduce the utilization of the needed and appropriate services. Consequently, the health of a patient may suffer. This poses the ethical question of distributive justice, where all persons have a right to healthcare provision (Sahin & Ramish, 2016). Additionally, managed care organizations are more interested in healthcare practitioners who provide optimal interventions with the least costly, intrusive, intensive, or extensive interventions capable of successfully addressing a problem. This is an almost impossible task for primary physicians to achieve and a morally wrong approach to individuals’ right to access health care.

References

Friedrich, C., & Lindeke, L. L. (2015). REIMBURSEMENT REALITIES FOR THE APRN. Advanced Practice Nursing: Core Concepts for Professional Role Development, 209.

Henkel, R. J., & Maryland, P. A. (2015). The risks and rewards of value-based reimbursement. Frontiers of health services management32(2), 3-16.

Holtrop, J. S., Luo, Z., & Alexanders, L. (2015). Inadequate reimbursement for care management to primary care offices. The Journal of the American Board of Family Medicine28(2), 271-279.

Sahin, Z. S., & Ramisch, J. (2016). Ethical Issues in Clinical Practice. Ethics and Professional Issues in Couple and Family Therapy, 233-252.

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Question 


Managed Care Organization (MCO) Article Summary

Understanding the complex process of accurate coding and billing is essential to a sustainable practice. As NPs, we are ultimately responsible for ensuring all coding and billing is accurate for each patient seen. For this Discussion, you will search the health care literature and summarize a peer-reviewed journal article published within the last five years.

To prepare:

  • Select one of the following topics:
    Managed Care Organization (MCO) Article Summary

    Managed Care Organization (MCO) Article Summary

    • Applying for Medicare and Medicaid Provider Numbers
    • Application process for National Provider Identifier Number
    • Incident to billing
    • Coding-Evaluation & Management
    • Fraudulent billing
    • Billing Self-Pay patients
    • Managed Care Organizations
  • Conduct a search and select a peer-reviewed journal article published within the last five years related to the topic you selected.

Note: For this Discussion, all students are to avoid all written work, which reviews or outlines coding and billing at previous or current worksites as well as previous or current practicum sites.

By Day 3
Post a brief summary of the article you selected. Include the key reimbursement issue addressed and how they would impact the NP in a collaborative practice versus and independent practice. Discuss an ethical or legal implication(s) associated with your article.

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