Who uses Policy and Procedures?

• A. Patients
• B. Government Agencies
• C. Managed Care Organizations
• D. Medical Staff

Answer: (C)

Policy and procedures are the formal rules organizations use to standardize how they operate and deliver care. In healthcare, managed care organizations rely on these documents to govern how the network runs, how providers are credentialed and privileged, how authorizations and utilization management are handled, and how quality programs are carried out. They create and enforce P&Ps to ensure consistency, compliance with contracts and regulations, and a predictable experience for members. Patients interact with these policies when seeking care or necessary approvals, and government agencies set and oversee the applicable rules, while medical staff follow them in their daily work—but the entity that creates, maintains, and enforces the policies is the managed care organization.