25 Apr

Webinar: Navigate Ethical AI Frameworks for Clinical Data and Healthcare Regulatory Compliance

Time: 10 a.m. to 11 a.m. (PT) | 1 p.m. to 2 p.m. (ET)

Register now
HITRUST
Program Audit Guide for Health Plans Program Audit Guide for Health Plans

    Name *

    Email *

    Company

    Phone

    Download Files

    Reporting

    • The State Regulatory Guidance (All Plan letters) responsibilities include, but are not limited to:
      1. DHCS All Plan Letter (APL) and Policy Letter (PL) Applicable Notices
      2. DHCS All Plan Letter (APL) and Policy Letter (PL) - Non-Applicable Notices
      3. Submits proof of APL and PL compliance documents to DHCS
    • The Organization Risk Assessment responsibilities include, but are not limited to:
      1. Review of new potential risks with assigned accountable business owners
      2. Provide final data set to senior executive team for implementation of agreed upon interventions
    • The Regulatory Audit Process responsibilities include, but are not limited to:
      1. Creation of audit folders
      2. Tracking of documents/universe and requests received from the auditor and distributed to the business owners
      3. Audit Readiness Questionnaires
    • The Regulatory Routine Reporting responsibilities include, but are not limited to:
      1. Maintaining calendar for all regulatory compliance
      2. Tracking timeliness of business owner’s submissions and attestation

    Monitoring

    Continuous monitoring allows a health plan to quickly and easily keep its finger on the pulse of the delegates’ performance to identify potential risks or issues before they become major problems. This will help ensure compliance with needed regulations through the health plan’s ability to:

    • Expedite feedback processes to mitigate operational and enterprise risks
    • Utilize streamlined reporting processes to automate reviews and highlight elements that are approaching identified tolerances
    • Track findings, recommendations and corrective action plans, as well as trends over time, to quickly compare delegates and prepare for renegotiation when the time comes

    Audit and CAP

    Auditing delegated entities is essential for maintaining good governance, managing risk and ensuring compliance within an organization. Health plans can now efficiently oversee audits and perform file reviews of their delegated entities and vendors and maintain a system-wide overview of all compliance activities:

    • Deliver real-time audit results
    • Lower audit backlog, efforts and timelines
    • Help health plans with pre- and post-delegation audits of all areas of delegation
    • Create and manage Corrective Action Plans (CAP) for all audits that produce findings

    Pre-delegation audit

    The pre-delegation audit process involves a comprehensive review of the proposed delegates’ policies, procedures, and systems, as well as an assessment of their compliance with relevant technical and operational standards. The audit may also include a review of their financial stability and management structure. Our module helps guide the process through:

    • Facility Site Review audits
    • Medical Record Review audits
    • Credentialing Audits Pre- and Annual re-certification
    • Utilization Management audits including Quality Management (QM) audits
    • Special Needs Plan (SNP) audits

    Delegation repository

    Centralized database of your various delegate or vendor information, allowing health plans to easily track and manage relationships with its FDRs.

  • Demographic information
  • Contact information
  • Responsibilities or functions assigned
  • Audit activities and past performance
  • CMS Program Audit Preparation Guide

    Healthcare regulations constantly change. To help create better Member Experiences, this eBook — CMS Program Audit Preparation Guide — is designed to help health plans improve program audit processes. This eBook emphasizes proactive risk assessment, monitoring, and audit practices and helps healthcare payers sustain continuous compliance.

    From how to prepare for CMS Program Audits to how to address remediation planning to how to leverage technology that streamlines processes, the CMS Program Audit Preparation Guide can be an invaluable resource. Download your free eBook today!

    Inovaare knows the world of Medicare, Medicaid and Commercial health plans from over 125 years of combined hands-on Regulatory Compliance department oversight. Our consultative approach guides health-plan compliance teams through everything needed to sustain a continuous audit-ready status and the Inovaare platform empowers them to submit CMS-compliant reports with the touch of a button. If you would like an in-depth discussion on how to meet the challenges of dynamic landscape of regulatory changes and stay compliant at all times, please call us at 1.408.850.2235 or Contact Us.

    Download your free Program Audit eBook today