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A Managed Care Organizations ( MCO ) utilize an array of important techniques to decrease the cost of care. From provider networks to formal utilization review and quality improvement programs, MCO are becoming a popular option in healthcare organizations. If you are thinking of transitioning to an MCO, the case study outlined below is a great resource.
Case Study: MCO
This Managed Care Organization (MCO) works with an extensive network of providers to serve the needs of a very sizeable population. As such, it required the services of an Independent Review Organization that would have the demonstrated capacity to handle high review volumes, while effectively managing the demands of its large and diverse provider network.
The MCO serves over 600,000 lives throughout 19 counties in its state. Nearly 21% of the people in the organization ’ s service are at or below the poverty level. The organization works in partnership with people who face significant challenges regarding substance abuse, mental illness, and/or developmen- tal disability. Itis committed to providing consistently excellent, person – centered, family – oriented services within a recovery – based system that is flexible and accessible, and which respects the individual ’ s freedom of choice. The former Local Management Entity (LME) experienced rapid expansion when it merged with several area organizations to become a Managed Care Organization in 2012.
One of the most significant challenges the organization faces is working effectively with its network of over 350 contracted providers. These include both full contracts and client-specific contracts. It works with 1,068 licensed practitioners, many of which operate in multiple counties and have more than one license, and/or are licensed clinicians within a hospital, CABHA, or agency. Additionally, the MCO providers bill a total of 183 different service codes, a factor which can further complicate the IRO process.
- The MCO found that integrating BHM’s IRO service was exceptionally simple.
- The first step was to go live with a fully customizable Peer Review System, a process which proved to be unexpectedly fast and trouble-free.
- The organization simply provided a list of the review criteria it required. Within days, BHM had precisely fulfilled each of the requests for custom content that the MCO had desired.
- Once this phase was completed, the MCO’s staff found it equally easy to learn and use the system.
- BHM provided complete training, with follow-up meetings to answer questions and provide user tips and support.
BHM’s IRO services consistently deliver the results the MCO hoped to achieve. On average, BHM IRO Services are saving the organization and its state’s taxpayers $2 million per year.