Question

Governance Categories FYI Contract Administration: Activities include adhering to contractual requirements, of employer groups, beneficiaries, and health care providers. Benefits Management: The division ensures that predefined populations receive health care coverage. Policy and Medical Management: The division determines procedures and other health services that require prior approval from the MCO medical staff and makes the determination on what type of medical cases require a clinical review before authorization for care can be granted. Provider and Member Services: Activities include providing customer service to policy holders and health care providers to ensure health care services are provided as agreed. Of the above 4, are there any that stand out as more/less challenging? Why or why not?

Answer 1

Answer: The contract includes Administration, benefits management, management and provider and member services. Out of this the most challenging one is the provider and member services as it includes activities which consists of the providing customer service to policy holders and health care providers. This is generally done to ensure that healthcare services are being provided as agreed. But this is a long term process and one cannot easily get proper response about the health care services. For example: Suppose a patient is getting a treatment and the healthcare professionals are doing their work with dedication, but according to the patient it is not complete satisfaction. So in this case there is a problem.