TABLE OF CONTENTS DELEGATED GROUPS

Transcription

1 TABLE OF CONTENTS DELEGATED GROUPS DELEGATION AND ADMINISTRATIVE SERVICES OVERSIGHT ADMINISTRATIVE OVERSIGHT PROGRAM AND PROCESS

2 DELEGATION AND ADMINISTRATIVE SERVICES OVERSIGHT Through a formal process of approval called Delegation, Alliance CompleteCare may give a provider entity the authority to perform certain functions on its behalf. These delegated or administrative functions may include, but are not limited to, utilization management, credentialing and network management, Part D administration, member enrollment/ disenrollment and reconciliation, after-hours customer service, health risk assessments, and claims processing. Alliance CompleteCare remains ultimately accountable for all services provided to its membership by provider entities, although functions may be delegated. Alliance CompleteCare oversees and evaluates the performance of its delegated groups and administrative contractors by: Reviewing routine periodic reports submitted by the group and contractor. Reviewing encounter data for capitated services and/or delegated services submitted by the group and contractor. Reviewing all coordination of benefits or third party liability recoveries for delegated services submitted by the contractor. Tracking and analyzing provider and member complaints, and other performance indices. Conducting periodic and annual reviews of systems, staff, and policies and procedures. 10-1

3 ADMINISTRATIVE OVERSIGHT PROGRAM AND PROCESS Delegated entities are expected to comply with all CMS regulatory requirements for their delegated functions. Delegated entities must also ensure that its downstream providers and sub-delegates adhere to the processes outlined in the Alliance CompleteCare manual. Compliance is a partnership between AAH, its delegated entities and each operational unit. There are seven elements of an effective oversight program as defined by the Office of Inspector General (OIG) and outlined in the Medicare Managed Care Manual (MMCM) Chapter 21. These seven elements are: Element I: Written Policies, Procedures and Standards of Conduct Element II: Compliance Officer, Compliance Committee and High Level Oversight Element III: Effective Training and Education Element IV: Effective Lines of Communication Element V: Well-Publicized Disciplinary Standards Element VI: Effective System for Routine Monitoring, Auditing and Identification of Compliance Risks Element VII: Procedures and Systems for Prompt Response to Compliance Issues INVOLVEMENT OF DELEGATED ENTITIES IN EACH ELEMENT OF THE ADMINISTRATIVE OVERSIGHT PROGRAM ELEMENT 1 Written Policies, Procedures and Standards of Conduct As discussed previously, all delegated entities are required to follow CMS rules and regulations and health plan rules, policies and procedures. CMS rules and regulations are released in several forms which include Medicare Managed Care Manual (MMCM) chapters, Health Plan Management System (HPMS) memos, and the annual CMS Call Letter. Health Plan policies and rules are found in the contract terms between AAH and its delegated entities, Alliance CompleteCare Provider Manual, and Provider Bulletins. Alliance CompleteCare and its delegated entities must perform the following activities under Element 1: Alliance CompleteCare must provide delegated entities its Code of Conduct, which explains the core values and expectations regarding ethical behavior for Alameda Alliance employees, board members, and delegated entities. Additionally, on an annual basis the Alliance Privacy Policy will be provided to each delegated entity. A copy of the AAH Code of Conduct and Privacy Policy can be found in on the Alameda Alliance for Health website 10-2

4 o o Code of Conduct - ( 0Conduct.pdf) Privacy Policy - Delegated entities must submit member communications to CMS for review and/or approval. Documents that delegated entities seek to have approved should be coordinated through Alliance Delegated Oversight. On an annual basis, delegated entities will be requested to attest their compliance with all CMS and Alliance CompleteCare policies, procedures, and requirements. The Alliance Medicare Compliance Officer will provide the attestation for signature. ELEMENT II Compliance Officer, Compliance Committee and High Level Oversight CMS requires that all Medicare Advantage and Part D plans have a compliance officer that is employed by the health plan. Alliance CompleteCare s Medicare Compliance Officer manages the day to day compliance responsibilities of the Medicare Advantage and Part D Programs. The Medicare Compliance Officer s contact information, along with all compliance and Fraud Waste and Abuse (FWA) reporting mechanisms can be found in Section 11. AAH has a Compliance Committee that is tasked with the oversight of the Delegated Oversight Program and regulatory compliance. The Compliance Committee meets at least on a quarterly basis. The Compliance Committee reviews monitoring reports for health plan and delegated entity audit activity, Corrective Action Plans (CAP) and updates. ELEMENT III - Effective Training and Education CMS requires that all staff, board members, and delegated entities that work on Medicare lines of business complete new hire and annual Medicare Compliance and FWA training. Additionally, function specific training should be completed, as needed. Record of these trainings should be maintained and include the dates of the training, training material, training sign in logs, and information on the person presenting the training. These records should be available to Alliance staff when requested and regular reports on completion rates will also be requested. Some mechanism should be established to demonstrate that the training is effective. Alliance CompleteCare will provide copies of the CMS-developed Medicare Compliance and FWA training to all delegated entities. A delegated entity will meet its training requirements by using the CMS-developed training. If the delegated entity prefers to utilize their own FWA and Medicare Compliance training, the delegated entity should provide a copy of their training to the Medicare Compliance Officer for review and verification that it contains all required elements. As mentioned, each delegated entity will be required to submit evidence that all employees have completed FWA and Medicare Compliance training. AAH will request this information from delegated entities as part of regular monitoring reports and through the annual audit process, as outlined in Element VI. 10-3

5 ELEMENT IV - Effective Lines of Communication CMS expects effective lines of communication between Alliance CompleteCare and its delegated entities. These communications include sharing CMS updates and information, as well as reporting information. Alliance CompleteCare shares this information utilizing both the Alliance CompleteCare Provider Manual and the Provider Bulletin. Critical information for delegated entities from CMS manuals, HPMS memos, and CMS annual Call Letters will be communicated to delegated entities through s from Delegated Oversight. ELEMENT V - Well-Publicized Disciplinary Standards CMS considers it critical to ensure compliance through consistent and clear publication of disciplinary standards for actions of non-compliance or FWA. Each delegated entity should establish, publish, effectuate, and report on consistent well publicized disciplinary standards. Terminations of employment due to instances of non-compliance or FWA that impact the Alliance CompleteCare lines of business should be reported to the Medicare Compliance Officer. ELEMENT VI - Effective System for Routine Monitoring, Auditing and Identification of Compliance Risks Alliance CompleteCare is tasked with ensuring routine monitoring and auditing to identify instances of non-compliance. Routine monitoring includes the review of regular reports on compliance items. AAH also completes an annual audit of each delegated entity, which is coordinated through Delegated Oversight. Part of the routine monitoring and auditing is self-monitoring and auditing, completed by the delegated entity. Alliance CompleteCare will request a copy of its delegated entities audit plan annually. Additionally should items of non-compliance be identified by a delegated entity, the identified items and Corrective Action Plans (CAPs) should be provided to the Alliance Medicare Compliance Officer. The Medicare Compliance Officer will request status updates on the delegated entity s progress in correcting the area of non-compliance. Alliance CompleteCare staff also complete an annual Risk Assessment. Items identified as high risk that impact any delegated entity will be communicated to the delegated entity once the Risk Assessment is completed. This will allow the delegated entity to put in place corrections to mitigate the high risk concerns. Based on this assessment, delegated entities may be asked to provide additional information in order for Alliance CompleteCare to ensure appropriate oversight of these identified areas. Delegated entities are requested to provide reports on CMS regulatory activity to evidence compliance with regulatory required activity. These reports are presented at Compliance Committee Meetings as described in Element II. These reports include items such as: 10-4

6 Provider and pharmacy network and demographic changes Provider credentialing and re-credentialing activities and metrics, including credentialing cycle turnaround time, ongoing monitoring results, and sanctions. Customer service call center metrics including member and provider complaints, benefit interpretation call volume, call abandonment rates, call hold time, and call answer speed. Encounter data for all capitated services. Financial statements, accounting, and check productions processes Utilization, care coordination, quality and pharmacy management, structure, programs, processes and metrics, including but not limited to, bed days/1000, average length of stay, admits per 1000, formulary management, over and underutilization reports, and UM/QI work-plan updates. Timeliness with Claims Processing, Denials and Approvals Timeliness with Prior Authorization Standard and Expedited Processing Timeliness with Member Notification of Claims and Prior Authorizations Completion Rates for Compliance and Fraud, Waste and Abuse Trainings Status of corrective action plans ELEMENT VII - Procedures and Systems for Prompt Response to Compliance Issues Alliance CompleteCare requires non-performing providers to submit a Corrective Action Plan (CAP). A CAP is a formal written response developed jointly by Alliance CompleteCare and the delegated entity that identifies all provider entity deficiencies cited during the audit and/or monitoring activity. The CAP addresses each deficiency, and outlines the corrective action(s) required from the provider including any actions necessary in order to prevent the deficiency from recurring. CAPs and status updates will be requested by the Medicare Compliance Officer who will also update the Compliance Committee and ultimately, the Alliance Board of Directors. If a delegated entity remains non-compliant with CMS requirements, the delegated entity is reviewed through the Compliance Committee, and Alliance CompleteCare retains the right to take final actions which may include but are not limited to: Placement of holds on member assignment to delegated entity. Revocation of delegation of all or parts of delegated or administrative functions. Termination of the delegated entity. If you have any questions about the delegation program or process, refer to your Alliance contract, Medicare Compliance Officer contact information in Section 11 and/or contact Provider Services for assistance. 10-5