Successful Delegation - HCCA Official Site

Successful DelegationAbove and Beyond Regulation and AccreditationHCCA 2011 Compliance Institute - 207April 2011Joyce Hall, RN, CPHQ, CHCBlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association. This document has been classified as public Information.Objectives Define DelegationIdentify Elements of a nationally recognizedDelegate Oversight ProgramReview Processes and Tools to BuildSuccessful Delegation RelationshipsShare Best Practice Tips, Tools and Ideas21

Defining DelegationA formal process by which an organization gives anotherentity the authority to perform certain functions on its behalf.Although an organization may delegate the authority toperform a function, it may not delegate the responsibility forensuring that the function is performed appropriately.– NCQA Health Plan Standards, 20113Defining DelegationThe process by which the organization contracts with orotherwise arranges for another entity to perform functionsand to assume responsibilities covered under thesestandards on behalf of the organization, while theorganization retains final authority to provide oversight to thedelegate.– URAC Health Plan Standards, Ver. 6.0, 200942

Defining DelegationCMS considers delegation a business relationship betweenthe organization and a first-tier entity to perform certainfunctions that otherwise would be the responsibility of theorganization to perform. The organization oversees and isaccountable for any functions or responsibilities that aredelegated to other entities whether the functions areprovided by the first-tier and other downstream entities.5Authority vs. AccountabilityRegardless of the definition, the plan is ultimatelyheld responsible–A health plan may give a delegate the authority to acton its behalf, but the organization remains accountable.63

Delegate vs. Vendor Delegate OversightUM, CM, DMClaims PaymentMarketingCredentialingBehavioral Health ServicesPharmacy BenefitManagementMember Enrollment Vendor ManagementSpecialty PharmacyClaims AuditIdentity Theft RecoveryMember TransportationContractsNon-traditional Providers7Committee Oversight Delegate Oversight Committee–Evaluates the quality of care and service provided to BCBSTmembers and practitioners by delegate/vendor organizationsthrough continuous oversight of the delegate/vendors’performance, program, regular reports, and correctiveaction/focus improvement plans as applicable84

Delegate Oversight Committee aidOperations9Accountability to the Governing BodyBoard of DirectorsChief Executive OfficerLeadership CouncilQuality Oversight CommitteeDelegate Oversight Committee105

Delegate Oversight Organizational ChartVP of PerformanceMeasurement and ImprovementDirector of Quality ManagementSpecial Project TechnicianDelegate OversightProject ManagerDelegate OversightProject ManagerDelegate OversightProject ManagerDelegate OversightProject Manager11Significant Growth in Delegated Services/Activities Currently 56 delegated vendors; increase of 92% armacy Benefit ManagerBehavioral HealthCase, Disease and/or Utilization ManagementHigh Risk OBOperations Call CenterCredentialing24/7 NurselineAir/Ground Transportation ServicesMarketing Data/MaterialsMedical Independent ReviewHigh Tech ImagingID Theft Restoration VendorClaims Analytics126

Delegate Oversight Processes Safeguard ComplianceSuccessfulDelegationAnnual EvaluationAssessment ofProgram andContract CompliancePerformance MonitoringReview ofContract Reporting Requirement CompliancePre-DelegationPre-selection CollaborationSuccessful ContractingPre-Delegation Evaluation13Delegate Oversight Processes Safeguard Compliance Pre-Delegation–Request for Proposal Support–Facilitation of Contracted Services Language–Development of Delegation Contract Language–Pre-Delegation Evaluation–Support Implementation Activities147

Delegate Oversight Processes Safeguard Compliance Performance Monitoring–Review of Performance Indicators at a minimum ofsemi-annually–Communicate routinely with Delegates–Focused Reviews and Corrective Action Plans aswarranted15Delegate Oversight Processes Safeguard Compliance Annual Evaluation–Must mirror contract–Desktop vs. Onsite–Includes Standards as well as Performancecompliance168

Tips, Tools and ConceptsDelegate Oversight templates ––––Delegate Services AgreementsEvaluation RoadmapsFile Review WorksheetsContract Checklists17Tips, Tools and Concepts Delegate Services Agreements––––––––Holds Delegate to BCBST business practice, regulation,and accreditation standardsRequires cooperation with QM and Delegate OversightactivitiesDefines the delegated function(s)States responsibilities of Delegate and BCBSTDefines reporting of performance indicators/measuresAddresses sub-delegationAddresses failure to meet expectations and correctiveactionAddresses documentation required for annual evaluation189

Tips, Tools and ConceptsIndicator DescriptionReportSchedulePre-Cert/Prior AuthNon-urgentQuarterlyTotal numberPerformance Goal1st Qtr2nd Qtr3rd Qtr4th QtrN/ADecision Timeliness94% - 24 hrs/1 businessday of decisionInitial NotificationTimeliness94% - 24 hrs/1 businessday of decisionConfirm StandardElectronic or Written94% - 24 hrs/1 businessday of decisionExcerpt from UM Performance Indicator Template19Tips, Tools and ConceptsCase Management FunctionsEntity Performing FunctionDelegateThe program content addresses the following: A description of the CMprogram including a definition of case management, overview,structure, goals and purpose of the programXIdentifies members for Case Management through the following sources:Claim or encounter dataHospital or Discharge dataPharmacy dataXBCBSTXData collected through the UM processes if applicableCase Management systems support:Evidence based clinical guidelines or algorithms toconduct assessment and managementAutomatic documentation of the staff ID, date and time of action onthe case action/interactionAutomated prompts for follow-upXExcerpt from CM Function Grid Template2010

Tips, Tools and Concepts Evaluation Roadmap Templates––––––Ensures consistency of delegate evaluationAddresses accreditation, regulatory, contractual andBCBST business practice elementsCites source of the guidelines – NCQA, URAC,Regulation, contract section and/or BCBST policyProvides example reference documents that may beused to support complianceRequires delegate to list reference materialsprovidedProvides reviewer comment section21Tips, Tools and l StructureThe delegate has a clearlydefined organizationalstructure outlining directand indirect oversightresponsibility throughoutthe organization.URAC CoreVersion 3.0,Core 01NCQA 2011 QI1 - Element A· Organizationalchart· Committeestructure· Program structure· Interview andObservation4Staff QualificationsStaff meets qualificationsas required in written jobdescriptionsURAC CoreVersion 3.0,Core 26 Job Descriptions File Review Policies andProcedures Attestation4ActualScoreReviewerCommentExcerpt from Core Roadmap Template2211

Tips, Tools and ConceptsScoringScoring Description4Total Compliance: Delegate meets all elements of the requirement.3Substantial Compliance: Delegate meets all primary elements of therequirement, but does not meet one secondary element.2Partial Compliance: Delegate meets all primary elements of the requirement,but does not meet two or more secondary elements.1Minimal Compliance: Delegate has a process or program that relates to therequirement, but does not meet all primary elements.0Non-Compliance: Delegate has no process or program that relates to theprimary elements of the requirement.N/ANot Applicable: Requirement or element does not apply to the delegate.90% - 100%Full Compliance80% - 89%Substantial Compliance70% - 79%Minimal Compliance 70%Non-CompliantBCBST Scoring Explanation23Tips, Tools and Concepts File Review Worksheets–––––Ensures consistency of delegate evaluationAddresses accreditation, regulatory, contractual andBCBST business practice elementsCites source of the guidelines – NCQA, URAC,Regulation, contract section and/or BCBST policyReflects accreditation requirementsReflects contractual requirements2412

Tips, Tools and ConceptsCaseNumberCaseStatusNCQA QI 7- D, EURAC CM 14NCQA QI 7 DURAC CM17NCQA QI 7 HBCBSTPracticeBCBSTPracticeContractSection DSA I- 20URAC CM 22BCBSTPracticeContractSection H - 4Evaluationof BenefitsMemberRightsprovided tomemberCriteria forOpeningCaseSF 12 Survey– MeasuringEffectivenessSSI EligibilityAssessmentTimeframe Met(30 days)Excerpt from CM Case File Review Example25Tips, Tools and ConceptsDocument RequirementMet in Section/PageAgreement to meet NCQA/URAC applicable standardsAgreement to meet CMS rules, regulations and letter rulingsAgreement to participate in onsite or desktop assessment at a minimum ofannuallyAgreement to provide BCBST access to medical records and othermaterials as needed to assess contract complianceRequire the vendor/provider to submit performance monitoring reports noless than semiannually to BCBST regarding the performance of thedelegated responsibilitiesRequire cooperation in development, implementation and completion ofcorrective action plan as indicatedRequire the initial and ongoing monitoring of employees against theExcluded Parties ListingSpecify that prior to sub-delegating any services/activities/functions, thevendor/provider must submit a written request to BCBST for approvalExample items that may be included on a Delegate Oversight Checklist2613

Tips, Tools and ConceptsGuideline orStandardFinding onDateCommentSample Corrective Action Plan Template27Share TimeWhat are your best practices?2814

Have we met our Objectives? Define DelegationIdentify Elements of a nationally recognizedDelegate Oversight ProgramReview Processes and Tools to BuildSuccessful Delegation RelationshipsShare Best Practice Tips, Tools and Ideasjoyce hall@bcbst.com2915

Successful Delegation Above and Beyond Regulation and Accreditation HCCA 2011 Compliance Institute - 207 April 2011 Joyce Hall, RN, CPHQ, CHC . Successful Delegation Relationships Share Best Practice Tips, Tools and Ideas. 2 3 Defining Delegation A formal process by which an organization gives another entity the authority to perform certain .