BUILDING BLOCKS > MANAGER

Administrative Function

What administrative functions do management entities perform?

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Quality Rating Systems

How does establishing a quality rating system increase the quality of services, facilitate oversight, and help consumers make informed care decisions?

Policy Definition: Organization and use of metrics to keep healthcare providers and systems accountable in terms of quality

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Analytics

How do analytics provide managers with real-time and forward-looking insights to manage risk and costs, develop care programs, and influence operations?

Policy Definition: Use of data by healthcare organizations and providers to gain and track insight into management, costs, patient records, etc.

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Claims Adjudication

How do insurers fairly determine their payment/financial responsibility after the member’s insurance benefits are applied to a medical claim?

Policy Definition: Once a claim is made to an insurance provider, adjudication is the process by which the insurer either accepts or denies responsibility for payment.

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Coding

○ How does accurate (and complete) coding ensure fair payment and help managers identify ways to improve quality and areas of focus/improvement?

Policy Definition: Medical coding is the transformation of health care diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician's notes, laboratory and radiologic results, etc source

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