There are several highly important managed care organization characteristics associated with the Olrberg contract. However, two of these key characteristics involve operational functions that include claims processing and member services. The first of these MCO characteristics, claims processing, is very key in the contract because it requires that Orlberg’s claim processing unit is knowledgeable and processes claims in a timely fashion per the contractual agreement. Processing claims correctly and timely ensures that Orlberg Hospital will be able to receive the funds owed to the organization by insurance providers and provide accurate differential billing to patients. In addition to ensuring that claims are processed correctly for the benefit of the patients and the hospital, it is a required component associated within the contractual agreement with Anthem to ensure that Orlberg will remain a network services provider.
Another key characteristic interacts directly with claims processing, which is having a skilled member services team. Orlberg’s member services department must be able to understand the definition of member and subscriber per insurance guidelines and per the contractual agreement with Anthem. Furthermore, member services must be able to effectively communicate billing issues, direct concerns to correct departments and assist patients with the collection of billed payments as well as understanding and often explaining the details within an individual’s bill. This can also mean working with members on helping understand explanation of benefits received from insurance providers and to also work with the claims department should medical procedures have been coded incorrectly or claims have been processed using poor data or information from the insurance provider, medical provider or the member.
Landon, B. E., Wilson, I. B., & Cleary, P. (1998). A conceptual model of the effects of health care orgnizations on the quality of medical care. Journal of the American Medical Association, 279(17), 1377–1382.