Delegation Oversight 101: How to Pass Oversight Audits Session Code: TU01 Time: 8:00 a.m. 9:30 a.m. Total CE Credits: 1.5 Presenter: Angela Dorsey,

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1 Delegation Oversight 101: How to Pass Oversight Audits Session Code: TU01 Time: 8:00 a.m. 9:30 a.m. Total CE Credits: 1.5 Presenter: Angela Dorsey, MA and Sallye Marcus

2 Delegation Oversight How to Pass Oversight Audits Presented by: Angela Dorsey, MA, Aetna Inc. Sallye Marcus, Anthem Inc. Agenda Introductions Definitions (NCQA, CMS, State) CR 1 Credentialing Policies CR 2 Credentialing Committee CR 3 Credentialing Verification CR 4 Recredentialing Cycle Length CR 5 Practitioner Office Site Quality CR 6 Ongoing Monitoring and Interventions CR 7 Notification to Authorities and Practitioner Appeal Rights CR 8 Assessment of Organizational Providers CR 9 Delegation of Credentialing Game Time! What Would You Do? Q & A Introductions Just a little something about your presenters: Sallye Marcus Angela Dorsey 1

3 Definitions Delegation: A formal process by which the organization gives another entity the authority to perform certain functions on its behalf. Although an organization may not delegate the responsibility for ensuring that the function is performed appropriately. Annual Audit: A health plan must conduct an audit at least every 12 months; 2-month grace period allowed (14 months). Definitions cont. Policies and Procedures: A documented process that describes the course of actions taken and the method in which the action will be carried out by the organization s staff to achieve objectives. Documented Process: Policies and procedures, process flow charts, protocols, and other mechanisms that describe the methodology used by the organization to complete a task. Evidence: Files, logs, spreadsheets, minutes, and agreements. NCQA: National Committee for Quality Assurance. Founded in 1990, NCQA drives improvement throughout the health care system. NCQA is a premier symbol of quality, and accreditation by the organization represents well managed and high quality care and service. Website: CMS: Centers for Medicare & Medicaid Services. The Centers for Medicare & Medicaid Services, CMS, is part of the Department of Health and Human Services (HHS). We administer Medicare, Medicaid, the Children s Health Insurance Program (CHIP), and parts of the Affordable Care Act (ACA). CMS must ensure that their members have access to high quality care. Website: 2

4 State Regulatory agency which can have credentialing regulations such as mandatory application, use of a universal organization to conduct primary source verification, and/or specific turnaround times for credentialing processes. CR 1 Credentialing Policies (Draft policies do not meet intent) Policies outline what and how credentialing procedures are completed within your organization. Reviewers will make sure the language in your policies meet the requirements listed below and will review evidence of implemented procedures as you have outlined in your policies. Types of Practitioners Verification Sources Criteria Decision Process Medical Director Sign off (Clean Files) Delegating Credentialing Nondiscriminatory Process Notifications to Practitioner (varying info, decisions) Description of Physician s Participation in Credentialing Program Confidentiality Practitioner Rights CR 1 Credentialing Policies (Draft policies do not meet intent) Performance Monitoring for Recredentialing Opt-Out Provisions Medicare Exclusion/Sanctions Timeframe Requirements 3

5 CR 2 Credentialing Committee Your organization s credentialing committee represents a decision making process that includes comprehensive advice from experts. Uses Appropriate Practitioners Reviews Practitioners Who Do Not Meet Criteria Clean File Review CR 3 Credentialing Verification This is the evidence piece that shows the reviewer that the elements outlined in your policies are followed. The reviewer pays close attention to verification sources used, criterion are appropriate for the State and specialty type of the practitioner, were the appropriate documents current at the time of the decision, and presented to the credentialing committee within appropriate timeframes. Valid License Valid DEA/CDS Education/Training Board Certification Work History Claims History Sanctions (State, Medicare/Medicaid) Application Elements CR 3 Credentialing Verification Clinical Privileges Performance Monitoring for Recredentialing Opt-Out Provisions Medicare Exclusion/Sanctions Timeframe Requirements 4

6 CR 4 Recredentialing Cycle Length This is the evidence piece that shows the reviewer that your organization s credentialing process properly recredentials it s contracted practitioners timely. Recredentialing Cycle Length CR 5 Practitioner Office Site Quality Your organization s practitioner s office sites meet quality standards and do not pose a safety or health hazard to patients. Performance Standards and Thresholds Interventions CR 6 Ongoing Monitoring Your organization has a process to monitor it s practitioner in-between credentialing cycles ensuring that they meet continued quality standards. Medicare/Medicaid Sanctions License Sanctions Complaints Opt-Out Provisions 5

7 CR 7 Notification to Authorities and Practitioner Appeal Rights Actions against a practitioner, for quality reasons, are handled with thoughtful consideration of the practitioner s and patient s needs. The reviewer will consider timeframes outlined in policies and ensure those timeframes are being met. Appeal Process Outlined Reporting Process Outlined Evidence of Formal Appeal Process Appeals for Terminations/Suspensions CR 8 Assessment of Organizational Providers Your organization has a process to ensure that the providers it contracts with meet quality standards. Assessment Process Review of Assessment of Medical & Behavioral Health Providers Additional Provider Types Timeframe Requirements CR 9 Delegation of Credentialing Your organization has a process for the oversight of entities in which it has entered into an agreement with to provide all or part of the credentialing process. Even though your organization has granted another entity to perform credentialing functions, it retains ultimate authority over the credentialing program and ensures that the entity is performing up to standards. Reviewers will want to audit all entities that perform credential functions on your organizations behalf. Delegation/Service Agreement Retaining Ultimate Authority Oversight Activities Reporting Language Provisions in Agreement 6

8 Keep in Mind Auditing NCQA Certified or Accredited Organizations State Requirements take Precedence Exchange Requirements Game Time What Would You Do? 7

9 Q & A 8