Medical Management

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At the heart of any high quality managed care organization is its medical management plan. Medical management programs are crucial to the performance of provider groups that engage in managed care activities. The structure, focus and sophistication of a medical management program is dependent upon the sponsoring organization, the amount and type of financial risk involved, and the physician reimbursement and incentive structure.

A medical management program consists of a series of activities undertaken by providers and managed care organizations (MCO's) to maintain or improve quality and service levels, meet budgetary projections, and respond to accreditation and regulatory requirements. It must focus on service delivery and maintaining high levels of customer satisfaction, often surveying members regarding their satisfaction with care, the process used to arrange care, and the vendors who provide the care.

The resources required to develop and maintain a medical management program depend on program goals. Many resources are already extant within the organization, including human resources such as clinical staff and analytical personnel, and capital resources like an appropriate MIS and telephone system. Clinical elements include

• Medical necessity criteria
• Preventive care guidelines
• Disease management guidelines
• Patient and provider satisfaction surveys

The MCR consulting team has worked in the areas of managed care and medical management for years, and can provide you with significant expertise in all the following areas.

• NCQA Standards
• Demand Management
• Quality Management Programs/Systems
• Utilization Review
• Case Management System Development

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