Making Delegated Entities Accountable and Enhancing Business Performance
Manage first-tier, delegated and related entities (fdr) to ensure compliance. Whether to gain expertise, reduce administrative costs or increase capacity, a Medicare Advantage plan sponsor may opt to outsource administrative functions. When they do, regulatory agencies like the Centers for Medicare & Medicaid Services (CMS)—as well as accrediting bodies, like the National Committee for Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC).
Plan sponsors—which can be employers, unions or health insurance carriers—must meet NCQA standards and demonstrate they haven’t compromised the ability to evaluate structures and processes that achieve consistent, high-quality performance across its network and memberships. The same applies for managed care organizations (MCOs), health plans that accept a set payment per patient per month, known as capitation; MCOs must demonstrate an ongoing oversight function to ensure continuous compliance is achieved for all delegated activities. Often, this is a labor-intensive process, requiring many reports and audit results to manage.
- Credentialing/Recredentialing
- Utilization management
- Quality improvement
- Claims processing
- Customer services
- Health and wellness
- Appeals and Grievances
- Disease and complex case management programs
- Utilization or quality management
FDR OVERSIGHT
lnovaare’s Delegation Oversight solution supports plan sponsors and MCOs to manage and track all audits they perform for delegated entities. Based on NCQA standards, Delegation Oversight monitors delegated functions to ensure NCQA survey teams consistently evaluate FDR performance and oversight.
Systematic review of FDR’s operations—to ensure they’re in line with business imperatives—is an important step in creating a culture consistent compliance that meets CMS oversight requirements. Delegation Oversight empowers plan sponsors and MCOs to evaluate their FDRs so they can develop and implement effective oversight programs that deliver secure business environments, automated alerts regarding potential issues and efficient remediation frameworks with suggested corrective action plans.
KEY BENEFITS
- Audit and monitor delegates
- Develop and establish FDR policies and procedures defined by plan sponsor and MCOs
- Online training module and an attestation process to comply with FWA
- Establish communication protocols and formal processes to support the sharing of information, including a centralized repository process flows, assumptions and change requests
FEATURES
- Configurable tool to manage NCQA audit and file review processes
- Quick turnaround time for change orders
- Role-based user access and control
- Project Management Office console to monitor multiple audits
- Built-in document management repository
- Content management module
- Multiple reports and dashboards
- Comprehensive help feature with linkages to published standards
- Automated alerts and notifications
- Assessment, compliance and program effectiveness in one solution
- Monthly and quarterly FDR data file upload efficiency
BUSINESS BENEFITS
- Ready-to-use web-based solution
- Reduced dependence on IT and support teams for audits
- Real-time view of audit status
- Lower audit backlog, audit efforts & timelines
- Decreased audit costs, ease of maintenance and communication for changes in orders
- Delegation audit system to perform both pre- and post-delegation audits, annually
- Risk scoring of delegated entities
- Delegation Oversight reviews, recommendations and/or corrective action plans can be initiated
FDR OVERSIGHT
Inovaare transforms healthcare organizations’ complex compliance processes through cloud-based software solutions that centralize data collected across disparate systems and departments, creating one efficient compliance management system. Designed as configurable automation modules, Inovaare’s comprehensive suite of HIPAA-compliant solutions empower healthcare payers to:
- Manage internal and external CMS compliance processes efficiently
- Monitor compliance data in real-time for increased status visibility
- Ensure audit readiness with CMS-compliant universes generated at the touch of a button
- Lower overall operating costs while reducing non-compliance risks