The assignment assesses competency 5. Investigate the key organizational functions of administering managed care programs, including contracting, reimbursement systems, utilization review, quality assurance, and plan management, 12. Critique cost and quality control mechanisms within managed care environments.

Directions: As employers look to control health care costs, MCOs have implemented utilization review protocols to ensure the right care is provided to patients at the right time. At the same time, employers, regulatory agencies and accreditation organizations have increased their expectations that the quality of care increases for patients receiving care through the MCO.

In no less than 4 and no more than 6 pages, write a paper that addresses the following:

• Define the key elements in utilization review and quality management.

• Compare and contrast these two functions and how they have changed over time.

• What role does each of these play in managed care? Be sure to think about this from employers who offer coverage to their employees; to regulatory agencies who provide oversight; and to private organizations that conduct external reviews.

• In your opinion, do these functions add value to managed care? Support your opinions with examples and your research.

• Cite references used in writing your paper.