Medical Loss Ratio |Get Solution

The below scenario is only to provide you with an example of a setting to frame the activity questions. The details of this scenario are not essential to answering the activity questions. You’re the chief operating officer of a Medicaid-managed care plan serving Medicaid and CHIP members in the southwest United States. You oversee overall operations of your health plan and assist your chief executive officer in defining and executing your health plan’s strategy. Although the financial and accounting operations fall under the responsibility of the health plan’s chief financial officer (CFO), you frequently meet with the CFO to identify initiatives that result in improved patient outcomes and reduced long-term costs. By federal law, your health plan’s medical loss ratio (MLR) is limited to 85%. If you exceed the MLR limit of 85%, the health plan is unable to recover the loss, so it’s essential that patient care is rendered when appropriate. Your health plan covers a variety of services that span the care continuum and contract with all types of providers to ensure your members’ needs are met. Coverage determinations are based on medical necessity and the use of evidence-based clinical guidelines. Utilization management (prospective, concurrent, and retrospective) is a particularly important area of health plan operations, as you want to ensure that care is only rendered when deemed appropriate, and this can help you manage your health plan’s MLR. You’re particularly interested in promoting prevention and wellness and identifying ways to empower your members to take control of their health. However, many of your members have complex medical needs that require high levels of care, so you’re faced with daily challenges of meeting your members’ needs while also ensuring your health plan is profitable. Describe what MLR is and how exceeding the 85% limit can result in financial losses. (25 points) Describe what’s meant by medical necessity and provide examples of excluded types of services. (25 points) Describe what evidence-based clinical guidelines are and how they’re defined. Explain some limitations or challenges associated with determining evidence-based clinical guidelines. (25 points) Describe the differences between prospective, concurrent, and retrospective utilization management. (25 points)

Don't use plagiarized sources. Get Your Custom Essay on
Medical Loss Ratio |Get Solution
Get a 15% discount on this Paper
Order Essay
Quality Guaranteed

With us, you are either satisfied 100% or you get your money back-No monkey business

Check Prices
Make an order in advance and get the best price
Pages (550 words)
$0.00
*Price with a welcome 15% discount applied.
Pro tip: If you want to save more money and pay the lowest price, you need to set a more extended deadline.
We know that being a student these days is hard. Because of this, our prices are some of the lowest on the market.

Instead, we offer perks, discounts, and free services to enhance your experience.
Sign up, place your order, and leave the rest to our professional paper writers in less than 2 minutes.
step 1
Upload assignment instructions
Fill out the order form and provide paper details. You can even attach screenshots or add additional instructions later. If something is not clear or missing, the writer will contact you for clarification.
s
Get personalized services with My Paper Support
One writer for all your papers
You can select one writer for all your papers. This option enhances the consistency in the quality of your assignments. Select your preferred writer from the list of writers who have handledf your previous assignments
Same paper from different writers
Are you ordering the same assignment for a friend? You can get the same paper from different writers. The goal is to produce 100% unique and original papers
Copy of sources used
Our homework writers will provide you with copies of sources used on your request. Just add the option when plaing your order
What our partners say about us
We appreciate every review and are always looking for ways to grow. See what other students think about our do my paper service.
Other
AWESOME
Customer 452813, July 5th, 2022
Business and administrative studies
GREAT
Customer 452813, June 30th, 2022
Nursing
This is great! Thank you
Customer 452679, December 16th, 2021
Nursing
As usual, the writers do amazing work.
Customer 452707, October 1st, 2022
ENVIRONMENT SCIENCE
GOOD
Customer 452813, June 19th, 2022
Web programming
outstanding!
Customer 452715, September 16th, 2022
Nurse
Great work! Thank you for the quality you put in each assignment.
Customer 452707, February 4th, 2022
Philosophy
i got the paper a bit late but it is good quality will for sure come back and use this website.
Customer 452611, September 9th, 2021
Other
Thanks for the help, appreciate it
Customer 452821, August 27th, 2022
Accounting
Thanks for your support
Customer 452701, February 3rd, 2022
Nursing
Great work. thank you again!
Customer 452707, August 7th, 2022
Other
NICE
Customer 452813, June 30th, 2022
Enjoy affordable prices and lifetime discounts
Use a coupon FIRST15 and enjoy expert help with any task at the most affordable price.
Order Now Order in Chat

SAVE BIG FOR FINALS. Order your essay today and save 20% with the discount code SPECIAL20