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Managed Care Consulting – Answering Some Frequently Asked Questions

Jan 19th 2015 at 1:53 AM

The concept of managed care consulting has come like a beacon of hope in an otherwise messed up, haywire and increasingly complex medical industry. This system has created many new and better ways in providing the right benefits to people who deserve assistance and care when they need it. But being relatively new, there are still many aspects of the concept that are shrouded in a cloud of confusion. In this article, we will attempt to deal with these issues and solve some of the most frequently asked questions related to manage care consulting.

What is provider profiling and how is it relevant?

When you seek to analyse and improve the healthcare services and the industry as a whole, you will need to find measures to understand the exact ground reality. A big part of the task is evaluating the practice patterns and policies of healthcare service providers. This function is known as provider profiling. Profiling is based on certain data that is used to benchmark providers against other comparable providers, select and recruit providers into an MCO network, and pay incentives to providers based on performance. There are many metrics involved in the process here including wait time to schedule appointments, admission policies, referral procedures, emergency protocols, satisfaction ratio for members and other patients as well as compliance with MCO clinical guidelines. All these aspects help in assessing the quality of a healthcare service provider and allow managed care consulting companies in assessing their potential.

What is patient eligibility information and what it its use?

The concept of managed care consulting also seeks to analyse the actual status of the member patients. The most important aspect that is analysed in this regard is patient eligibility. Eligibility is the determination of whether an individual is covered by a health plan. This information subsequently determines the kind of services that will be rendered by a healthcare institution towards the patient in question. This information is used by providers to determine how a patient should be billed and how the health plan should reimburse the provider. This system uses many data collection means to gather information in this regard and keep the MCO updated about the ground reality of things. Patient eligibility checks also prevent unauthorised use of healthcare plans and misappropriation of hard-to-come-by resources.

What is encounter data and why is it required?

Encounter data can be basically defined as information generated by patient visits to a healthcare service provider for seeking outpatient as well as ambulatory services. The compensation that a provider will receive for the services he/she renders is dependent upon this data. This data is collected and recorded through various means and allows the managed care consulting companies in tracking of services, assessing the risks involved and make adjustments in the plans based on patient populations. Other uses for encounter data involve quality improvement and prevention programs related to the tracking of types of care and sites of care.

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About The Author

Richard Beckett is an expert in elderly care and highly recommends availing of services of home care professionals in your city. He recommends as the best and most reliable agency for providing services of home care in Brighton.

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