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 |
|---|---|
| FDR Management |
|
| FDR Workflow and Collaboration |
|
| FDR Portal |
|
| Universe Management System |
|
| Reports |
|
| Dashboards |
|