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)

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Delegation Oversight Solution for Medicare Advantage plans Delegation Oversight Solution for Medicare Advantage 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

    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
    • 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
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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 delegated 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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