Overview Of Delegation In Managed Care

Overview of Delegation in Managed Care

I. Overview of Delegation

A. Defin ition of delegation

1. 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.

B. When evaluating a delegation agreement, a credentialing specialist must determine:

1. If the delegation agreement contains all the required elements for compliance with accreditation entity, federal and state laws

2. Mutually agreed upon

3. describes the responsibilities of the organization and the delegated entity

4. describes the delegated activities

5. requires at least semiannual reporting to the organization

6. Describes the processes by which the organization evaluates the delegated entity’s performance

7. Describes the remedies available to the organization if the delegated entity does not fulfill its obligations, including revocation of the delegation agreement

II. Constructing a Delegation Agreement

A. Written Delegation Agreements Content

1. Provisions for PHI (Protected/Private Health Information)

2. Right to Approve & Terminate

3. Responsibilities of Organization and Delegate

4. Delegated Activities

5. Semi-Annual Reporting

6. Evaluation of Performance

7. Remedies for Revocation

III. Pre-delegation Evaluation Process

A. The organization must have a systematic method for conducting this evaluation, especially if more than one delegation agreement is in effect.

1. 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.

2. The organization must evaluate the delegates’ credentialing system and schedule for compatibility with its own.

B. 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.

1. At a minimum, an audit must include at least 10 credentialing files and 10 re-credentialing files.

2. The organization may use the NCQA 8/30 methodology available at www.ncqa.org/updates to review the delegate files for both credentialing and recredentialing.

C. Exception to PreDelegation Audit Requirement:

1. If the delegate is an NCQA accredited or certified organization in the areas of credentialing and recredentialing.

D. Pre-Delegation Audit

1. When 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.

IV. Delegation Oversight/Annual Audit

A. There must be yearly documentation of substantive evaluation and actions plans, if needed.

B. The annual audit and evaluation must be based on the responsibilities stated in the mutually agreed-upon delegation document and the appropriate NCQA standards.

C. The evaluation must include a review of the delegate’s credentialing policies and procedures

D. An 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.

E. 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 cycles

F. Exception to Annual Audit Requirement: If the delegate is and NCQA accredited or certified organization in the areas of credentialing and re-credentialing.

V. Evaluation Reporting

A. The organization must receive and evaluate reports from its delegates at least semiannually.

1. At a minimum the following must be included in the reports:

a. progress in conducting credentialing and recredentialing activities

b. performance improvement activities, if applicable

B. Findings 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.

1. Areas can be related to NCQA credentialing standards or to the organization’s expectations

C. Reporting 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.

VI. Reporting

A. What to report

1. Progress in conducting credentialing and recredentialing activities

2. Performance improvement activities

B. Sources to identify improvement

1. Findings from predelegation evaluation

2. Findings from annual evaluation and file audit

3. Ongoing Reports

4. Credentialing Committee Minutes

5. Data Analysis

6. Reports designed specifically for relationship

C. NCQA-Certified or NCQA-Accredited Entities

1. Delegate must be NCQA-certified or NCQA-accredited prior to the implementation of the delegation agreement

2. For certification, the benefits are awarded for those elements/categories for which the delegate has achieved certification

3. Activities must be covered in the agreement

D. Why use NCQA-Certified or NCQA-Accredited Entities ?

1. Relief from pre-delegation assessment requirements

2. Relief from the annual performance evaluation

3. Automatic credit on certain delegated activities

E. Scope of NCQA Evaluation

1. Within scope

a. Primary care

b. Specialty care

c. BH organizations

d. CVO’s

e. PBM’s

f. DM

2. Out of scope

a. Home health agencies

b. Vision service providers

c. Lab organizations

09/2014