Overview of Delegation in Managed Care



Overview of Delegation in Managed CareOverview of Delegation Definition of delegation A formal process by which the organization gives another entity the authority to perform certain functions on its behalf. Although the organization may delegate the authority to perform a function, it may not delegate responsibility for ensuring that the function is performed appropriately.When evaluating a delegation agreement, a credentialing specialist must determine:If the delegation agreement contains all the required elements for compliance with accreditation entity, federal and state lawsMutually agreed upondescribes the responsibilities of the organization and the delegated entitydescribes the delegated activitiesrequires at least semiannual reporting to the organizationDescribes the processes by which the organization evaluates the delegated entity’s performanceDescribes the remedies available to the organization if the delegated entity does not fulfill its obligations, including revocation of the delegation agreementConstructing a Delegation Agreement Written Delegation Agreements ContentProvisions for PHI (Protected/Private Health Information)Right to Approve & TerminateResponsibilities of Organization and DelegateDelegated ActivitiesSemi-Annual ReportingEvaluation of PerformanceRemedies for RevocationPre-delegation Evaluation Process The organization must have a systematic method for conducting this evaluation, especially if more than one delegation agreement is in effect. Evaluation usually involves a site visit and a written review of the delegate’s understanding of the standards and the delegated tasks, staffing capabilities and performance records, but it may also be accomplished through the exchange of documents or through pre-delegation meetings. The organization must evaluate the delegates’ credentialing system and schedule for compatibility with its own.The organization audit must include either 5 percent or 50 of its practitioner’s files, whichever is less to ensure the information is appropriately verified. At a minimum, an audit must include at least 10 credentialing files and 10 re-credentialing files. The organization may use the NCQA 8/30 methodology available at updates to review the delegate files for both credentialing and recredentialing.Exception to PreDelegation Audit Requirement: If the delegate is an NCQA accredited or certified organization in the areas of credentialing and recredentialing. Pre-Delegation AuditWhen evaluating a delegate’s credentialing system to ensure compatibility with your own, it is important to ensure their practice standard is equivalent with your own. This can be done by a thorough review of their policies and procedures. Delegation Oversight/Annual Audit There must be yearly documentation of substantive evaluation and actions plans, if needed. The annual audit and evaluation must be based on the responsibilities stated in the mutually agreed-upon delegation document and the appropriate NCQA standards.The evaluation must include a review of the delegate’s credentialing policies and proceduresAn organization that conducts annual file audits of delegates one year is not required to conduct annual file audits when the delegate does not credential or re-credential any practitioner’s until the next file audit is scheduled to occur. The organization is required to meet all other delegation oversight requirements and provide documentation that the delegate did not credential or re-credential practitioner’s between the audit cyclesException to Annual Audit Requirement: If the delegate is and NCQA accredited or certified organization in the areas of credentialing and re-credentialing. Evaluation Reporting The organization must receive and evaluate reports from its delegates at least semiannually. At a minimum the following must be included in the reports: progress in conducting credentialing and recredentialing activities performance improvement activities, if applicableFindings from the organization’s pre-delegation evaluation, annual evaluation and file audit or ongoing reports can be sources to identify areas of improvement for reporting. Areas can be related to NCQA credentialing standards or to the organization’s expectationsReporting may be limited to lists of credentialed and re-credentialed practitioner’s if no performance issues are identified and that is the only other requirement specified in the delegation agreement.ReportingWhat to reportProgress in conducting credentialing and recredentialing activitiesPerformance improvement activitiesSources to identify improvement Findings from predelegation evaluationFindings from annual evaluation and file auditOngoing ReportsCredentialing Committee MinutesData AnalysisReports designed specifically for relationshipNCQA-Certified or NCQA-Accredited EntitiesDelegate must be NCQA-certified or NCQA-accredited prior to the implementation of the delegation agreementFor certification, the benefits are awarded for those elements/categories for which the delegate has achieved certificationActivities must be covered in the agreementWhy use NCQA-Certified or NCQA-Accredited Entities?Relief from pre-delegation assessment requirementsRelief from the annual performance evaluationAutomatic credit on certain delegated activitiesScope of NCQA EvaluationWithin scopePrimary careSpecialty careBH organizationsCVO’sPBM’sDMOut of scopeHome health agenciesVision service providersLab organizations ................
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