Reporting
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The State Regulatory Guidance (All Plan letters) responsibilities include, but are not limited to:
- DHCS All Plan Letter (APL) and Policy Letter (PL) Applicable Notices
- DHCS All Plan Letter (APL) and Policy Letter (PL) - Non-Applicable Notices
- Submits proof of APL and PL compliance documents to DHCS
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The Organization Risk Assessment responsibilities include, but are not limited to:
- Review of new potential risks with assigned accountable business owners
- Provide final data set to senior executive team for implementation of agreed upon interventions
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The Regulatory Audit Process responsibilities include, but are not limited to:
- Creation of audit folders
- Tracking of documents/universe and requests received from the auditor and distributed to the business owners
- Audit Readiness Questionnaires
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The Regulatory Routine Reporting responsibilities include, but are not limited to:
- Maintaining calendar for all regulatory compliance
- 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.
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
The Challenge with Manual Delegation Oversight
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
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 |
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FDR Management |
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FDR Workflow and Collaboration |
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FDR Portal |
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Universe Management System |
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Reports |
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Dashboards |
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