GETTING DELEGATION “RIGHT”

NCQA Standards on Delegation are complex regardless of your NCQA program. It is essential to get it right because of opportunities for automatic credit and high points. But more importantly, these are members for whose care you are accountable. That should not be taken lightly. NCQA's position is that when you delegate, the care and service should be just as high as if you were providing it yourself instead of delegating it to another organization.

Delegation standards are filled with requirements for performance oversight, reporting, file audits, and collaborative efforts for quality improvement and system controls monitoring.

Before we get to tips on pre-delegation, delegation, and oversight, let’s first look at some unfortunate situations MHR clients encountered over the years before deciding to collaborate with us for expert assistance.

Cautionary tales and situations to avoid

When delegation arrangements are first drafted, some accountable parties on either side--organization or delegate--may be unfamiliar with NCQA standards. Data needs, reporting, and system controls may not be in place. Points are lost when the organization does not provide its documentation or does not provide it early enough to the consultant to review and assist in mitigating the risk.

Are any of these situations familiar?

• A Health Plan terminates its contract with an NCQA Accredited delegated healthcare provider, and its new provider is not NCQA Accredited, causing the Health Plan to lose automatic credit for its file review because the new provider's files were within the Health Plan’s look-back period.
• An organization did not conduct a pre-delegation assessment of a new delegate within 12 months before the delegation began to evaluate the delegate’s capacity to meet NCQA requirements, resulting in lost points.
• A delegate was not compliant with the more recent system controls requirements, having failed to implement them within its look-back period.
• Insufficient oversight by a delegate of a sub-delegate resulted in noncompliance with performance oversight.
• Finding out what you considered a "vendor" was actually a "delegate,” and now the entity will be reviewed by NCQA as a delegate without advanced preparation and possible loss of points.
• Documentation was insufficient to demonstrate ongoing performance oversight.
• Contracts executed by persons unfamiliar with NCQA Delegation requirements resulted in needing subsequent amendments to its Delegation Agreement.

Ensure that parties from across your organization are involved and accountable for varying aspects of delegation arrangements such as IT, legal, contracting, medical review, quality improvement, and the specific functional area.

Pre-delegation Evaluation

Pre-delegation evaluation determines if the potential delegate has the capacity to meet NCQA requirements and if any non-compliant areas need correction before the delegated activity begins. NCQA’s explanations include specific pertinent details to follow.

Helpful tips:

1. Verify that the organization is either a delegate, sub-delegate, or vendor. NCQA’s Standards and Guidelines Appendix 2 for Delegation, along with the specific standards, provide direction and should be read carefully.
2. Perform your evaluation before the delegated service begins. No services by the delegate should ever be provided prior to the mutually-executed Agreement being in place. Even if the delegate is NCQA Accredited and you could receive automatic credit for this function, you are still allowed to evaluate the delegate such as asking for their policies, reports, and files to review.
3. Note and track the NCQA status and next survey date for the accredited or certified organizations. This includes programs accredited (PHP, CM, and WHP) and for MBHOs, and the product line(s) that are accredited.
4. Review the delegate’s applicable policies and procedures, including their next review date.
5. Adding new activities to a delegate at any time requires an additional, documented, pre-service evaluation of that new activity. This NCQA stipulation is commonly missed by organizations but is clearly in the standards and would require an amendment to the Agreement describing new delegated activities.
6. Determine and record the percentage of membership impacted by the delegate.

 Include in your organization’s procedure for conducting a pre-delegation evaluation the use of an audit tool to demonstrate to NCQA your adherence to pre-delegation practices. MHR has a suite of delegation oversight and monitoring tools that can be purchased if organizations need assistance in this important function.

Delegation Agreement

Delegation Agreements for all delegated programs include factors related to mutual Agreement, responsibilities for both parties, annual performance monitoring, file audits as applicable, semi-annual reporting, and remedies, including revocation of delegation for non-performance. In addition, standards on UM, CVOs, and CR have requirements for system controls.

Helpful tips:

1.  Include within the Agreement the date by which the delegation arrangement is effective and activities are initiated. Without a date, NCQA considers the executed date of the Agreement as the effective date. This date is critical when establishing your look-back period and subsequent annual monitoring requirements.
2. List detailed reporting requirements within the Agreement to ensure mutual understanding. For example, do you want reporting specific to product lines or to assist with determining health equity programs? In addition, NCQA has provided further direction to MHR :
   • Listing “Reports to be determined” for the Delegation Agreement does not meet NCQA requirements, as organizations cannot hold the delegate to something unclear, since this is a legal document.
   • When there is a self-serve portal for reports, the Agreement must be clear regarding what is accessed, who accesses it, and the frequency of access.
3. Changes in organizational structure, ownership, or new delegated services may be causes to update the Delegation Agreement.
4. Consequences for the failure of the delegate to perform its responsibilities must be explicit. For example, the consequences of repeatedly failing to submit timely reports may differ from repeatedly failing on timely UM decision-making.

NCQA Standards on Delegation, regardless of your NCQA program, are specific for all NCQA products: Health Plans (HPA), CR, ME, LTSS, NET, PHM, QI, PHM (including CM), UM, and Health Equity. These are frequently delegated to organizations such as behavioral health organizations, physician organizations (who may do UM, CR, PHM for telehealth and chiropractic), specialty population health organizations that address specific diseases, CVOs, case management organizations, technology companies that provide health appraisals and self-management tools, dental, vision, mailing companies, and many others. Organizations not experienced with NCQA should seek assistance from MHR to apply the appropriate NCQA standards to each Agreement.

Delegation Oversight

Organizations monitor the ongoing performance of their delegates and vendors according to their own documented policies and procedures.

Oversight becomes increasingly complex with the following:

• Multiple or limited products, product lines, and multiple states
• Multiple delegates, vendors, and functions delegated
• Requirements for files and system controls
• New or changes in delegated functions
• Lack of standardized delegation processes and procedures and auditing tools
• Inexperienced staff to conduct oversight
• Inexperienced NCQA project leads to prepare for an NCQA survey
• Lack of organizational structure to effectively monitor performance
• Lack of a quality improvement structure to enhance performance

To help simplify the complexity of delegation, ask us about our:

• delegated oversight program guides
• tools for each set of delegated standards
• checklist for delegation agreements
• training session on delegation

Call to Action:

• Start the new year with an audit of your delegated agreements, responsibilities, and performance-monitoring activities, along with vendor contracts
• Assess staff’s knowledge of delegation
• Anticipate any new upcoming delegated arrangements, which require connection and ongoing communication with the contracting staff
• Ask MHR about our suite of delegation tools and trainings.