decisionhealth Newsletters, Answer Books - 2009 Issue 3 (March)
Managed Care Model Compliance Plan / Quality Assurance
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Article Overview
This article discusses a managed care model compliance and quality assurance framework. It covers how plans can monitor access to care, utilization patterns, denials, and member feedback using internal databases, survey results, medical record review, and grievance/appeal tracking. The content is relevant to compliance staff, managed care administrators, utilization management teams, and health plan quality assurance personnel who need a broad overview of oversight activities and reporting processes.
Why This Topic Matters
Managed care organizations rely on structured monitoring to identify access problems, underutilization, inappropriate denials, and coordination-of-care issues. Understanding the article helps readers assess whether their compliance and quality assurance programs capture the right data and support ongoing oversight.
What You Will Learn
- How managed care plans can organize compliance and quality assurance monitoring activities
- What kinds of utilization and access data are commonly tracked in a managed care oversight program
- How enrollee surveys, exit interviews, and grievance/appeal records can inform quality review
- Why database-based reporting and trend analysis are important for compliance oversight
Who Should Read This
- Managed care compliance staff
- Health plan quality assurance personnel
- Utilization management teams
- Medical affairs departments
- Managed care administrators
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