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Delegation Oversight Solution for Health plans Delegation Oversight Solution for Health plans

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    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

    • The Enterprise Monitoring and Oversight workstream responsibilities include, but are not limited to:
      1. CMS Program Audit universe scrubber (for all universes)
    • The Federal Regulatory Guidance (CMS HPMS memos) responsibilities include, but are not limited to:
      1. Tracking of regulatory guidance changes (2017 Medicare Marketing Guidance Changes)
      2. Maintenance of the 2018 Call Letter Grid that illustrates deliverables by business units

    Audit and CAP

    • The Internal Audit workstream responsibilities include, but are not limited to:
      1. Review of prior and current year ORA risks
      2. Initiates Management Action Plans (MAP) for all audits that produce findings

    Pre-delegation audit

    Pre-Delegation Audit, Healthcare Delivery Organization (HDO) Credentialing, HDO Initial Credentialing, HDO Re-credentialing and Re-credentialing.

    • Facility Site Review audits, specifically audit of medical facilities/sites
    • Medical Record Review audits, specifically audit of medical records
    • Utilization Management audits include:
      1. UM audits
      2. Quality Management (QM) audits
      3. Special Needs Plan (SNP) audits
      4. Service Denial audits

    Pre-delegation audit

    Credentialing, Facility Site Review (FSR), Medical Record Review (MRR) and Utilization Management (UM).

    • Credentialing audits include:
      1. Adverse Action Monitoring
      2. Annual Credentialing
      3. Credentialing Initial File
      4. Credentialing
    Inovaare

    Delegation Oversight Overview

    Delegation Oversight (DO) administrators, DO leaders and first-tier, downstream or related (FDR) entity auditors understand they can delegate the function, but not health plan’s responsibilities. This is why the following processes are critical to an effective Delegation Oversight program:

    • Establish a Delegated Oversight Committee
    • Conduct pre-contract audits of all delegated entities
    • Receive monthly/quarterly monitoring reports from all FDRs
    • Perform annual audits of all delegates
    Schedule a demo
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    The Challenge with Manual Delegation Oversight

    Resources management

    To ensure CMS regulatory compliance requirements are enforced, plan sponsors must monitor the activities of their delegated entities continuously to sustain regulatory compliance, whether they outsource:

    • Credentialing
    • Utilization Management
    • Care Management
    • Claims Management
    • Behavioral Health Services
    • Pharmacy Benefit Management

    With the ever-changing Centers for Medicare and Medicaid Services (CMS) regulatory requirements, health plans are turning to enterprise software to achieve the following business objectives:

    Sustain a regulatory framework
    Establish a contractual framework
    Achieve unified oversight across all delegates
    Implement a continuous audit and monitoring program

    Delegation Oversight software helps reduce the overall cost of data collection and analysis, from which health plans can effectively advise their delegates. And, if it has the latest CMS protocols, business rules and logic built into it, health plans can improve external audit responses and ensure timely regulatory requirements.

    The Solution: Delegation Oversight Software

    Inovaare’s Delegation Oversight software suite, a cloud-based automation and workflow solution, helps health plans to systematically conduct audits and perform file reviews of FDRs to create a culture of compliance. This essential Delegation Oversight software suite can help Delegation Oversight, Delegated Entity and FDR Audit personnel within health plans to:

    • Deliver real-time audit statuses
    • Lower audit backlog, efforts and timelines
    • Conduct efficient pre- and post-delegation audits
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    Designed by health plan industry experts and built upon a Compliance Operations Platform, Inovaare’s Delegation Oversight software empowers health plans to drive DE compliance through the following product features:

    Delegation Repository
    Pre-delegation audit
    Audit and CAP
    Monitoring
    Reporting

    Key Delegation Oversight Software Benefits

    The Delegation Oversight software suite enables health plans to:

    • Expedite delegate onboarding with a criteria-based evaluation tool that automates the delated entity (DE) pre-determination/credentialling process
    • Conduct audits of FDRs on demand, based on real-time rendering of DE demographics data, which are then correlated with contact information and contract details via a secure repository
    • Plan and execute internal audits of FDRs via a workflow automation tool
    • Generate reports and dashboards that provide actionable insights and corrective action plans for outliers
    • Monitor the compliance level of FDRs via thresholds and tolerance metrics
    • Enhance DE user experience with a dedicated FDR portal that includes a Delegation Oversight Universe Scrubber for generating and submitting accurate, CMS-compliant universes
    • Improve the performance of delegating divisions with performance scorecards of FDRs, drill-down reports and dashboards

    Delegation Oversight Software Suite

    Module Features
    FDR Management
    • Demographics
    • Delegated Functions
    FDR Workflow and Collaboration
    • Audit Calendar
    • Audit Program Workflow
    • Issue Tracker
    • Corrective Action Plan (CAP)
    • Task Management
    FDR Portal
    • Task and Email
    • Web Portal
      1. Self-Registration
      2. CAP Response
      3. FDR Universe Scrubber
      4. Audit Response Request
    Universe Management System
    • System-Generated Universes
      1. COA
    • Universe Scrubber
      1. All CMS tables
    Reports
    • Audit Schedule Report
    • Audit Summary Report
    • Detail Audit Report
    • CAP
    Dashboards
    • Audit Score Card
    • Trend Analysis
    • Comparison
    • Audit Schedule
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