Author Question: What are the various mechanisms by which an MCO can generate ... (Read 49 times)

CQXA · **on:** Jul 12, 2018

What are the various mechanisms by which an MCO can generate revenue?

Question 2

Compare and contrast the various organizations that can provide an MCO with accreditation.

TDubDCFL · **Reply #1 on:** Jul 12, 2018

Answer to Question 1

Premium payments represent the primary revenue for an MCO. Premiums can come from employers, individuals, individual states on behalf of their members, or CMS.

Answer to Question 2

NCQA: an independent nonprofit organization that develops new standards separate from those of trade associations. In 2010, NCQA offered accreditation programs for health plan accreditation, wellness and health promotion, and managed behavioral health care organizations, new health plans, and disease management.
The Joint Commission: each part of the entity may be accredited individually by The Joint Commission.
AAAHC: accredits the health care delivery portion of staff model, group model, and network model HMOs. AAAHC uses the Accreditation Handbook for Ambulatory Health Care to survey the physician office and clinic portions of these HMOs. The focus of this accreditation is on the delivery of health care rather than the insurance aspects of the HMO or MCO.
URAC: publishes both health plan and health network standards. The Health Plan accreditation program provides a comprehensive review of health plan operations in five areas and is appropriate for HMOs and other integrated plans. The Health Network accreditation does not include utilization management and is better suited for PPO accreditation.