Health care organizations continually face challenges from various regulatory and government agencies while also being bound by Managed Care Organization (MCO) standards.

1. Two key reform factors that will need to be addressed by future health care workers or leaders based on the video “College of Nursing and Health Care Professions: Do We Know What Our Future Is?” are:

a) The need for a patient-centered care model: The video highlights the shift from a provider-focused model to a patient-centered care model, which requires health care workers and leaders to prioritize patients’ needs and preferences. This model requires increased patient engagement and involvement in the decision-making process and a focus on patient outcomes.

b) The need for technology integration and innovation: The video discusses the importance of integrating technology into healthcare, as it can improve communication, increase access to care, and improve patient outcomes. Future healthcare workers and leaders will need to be adept at implementing and using technology to improve patient care.

Adherence to MCO standards plays an important role in my future healthcare vision. Managed care organizations aim to improve patient outcomes while containing costs. By adhering to MCO standards, healthcare organizations can ensure that they are providing high-quality, cost-effective care. Adherence to MCO standards also fosters accountability, as healthcare organizations are required to report on quality measures and outcomes.

2. The Affordable Care Act (ACA) includes several requirements related to provider compliance with fraud, waste, and abuse laws. Three of these requirements and corresponding measures that health care organizations can initiate to comply with the ACA are:

a) Developing and implementing compliance programs: The ACA requires providers to have compliance programs in place to prevent fraud, waste, and abuse. The program should include policies and procedures, training and education, and monitoring and auditing. A study by Mixon et al. (2017) found that implementing compliance programs can significantly reduce the risk of fraud and abuse.

b) Screening employees and contractors: The ACA requires providers to screen employees and contractors to ensure that they are not excluded from federal health care programs. The screening process should include checks for criminal history, licensure, and exclusions. A study by Ghanem et al. (2018) found that employee screening can reduce the risk of fraud and abuse.

c) Reporting and returning overpayments: The ACA requires providers to report and return overpayments within 60 days of identification. Providers should establish processes to identify and investigate potential overpayments, and to ensure timely reporting and return. A study by Kocot et al. (2016) found that implementing processes to identify and return overpayments can help providers comply with the ACA and avoid penalties.

References:

Ghanem, K. G., Gibbons, R. V., Young, B. E., & Lai, L. D. (2018). Employee screening: A critical step in preventing health care fraud and abuse. Journal of Health Care Compliance, 20(1), 47-57.

Kocot, S. L., Dresang, L. T., & Shugarman, L. R. (2016). Health care provider overpayment reporting and returning: a review of regulations, guidelines, and best practices. Rand Health Quarterly, 6(3), 6.

Mixon, A. S., Gomillion, A. B., McNeil, C. R., & Reilly, C. A. (2017). The effectiveness of compliance programs in preventing fraud, waste, and abuse in the Medicare program. Health Care Management Review, 42(2), 146-156.