Delegation Nation

Ongoing monitoring and auditing is a widespread challenge, but they are must-dos according to CMS’ compliance program requirements. You have some tools, but not enough to capture the full picture. Responsibilities are spread out between departments and delegated entities. Is the risk assessment just a matter of asking for a list of risks, or is it simply a review of the OIG work plan? It’s just not enough. Where does your sanity check fall on your annual risk assessment, let alone your daily planner?

When the decision is made to outsource a part of your Medicare Advantage or Part D responsibilities, the onus continues to be on the Plan Sponsor for compliance. That means effective pre-delegation site-visits, collaboration in monitoring and information exchange, and a delegate’s demonstrated commitment to meet your organization’s needs.

Many Medicare Compliance Officers don’t have the resources to fully monitor and oversee the delegates. You get some reports, but then hear from another plan that your biggest delegate is having problems. Now CMS is asking you what you know about it. What systems do you have in place for routine and ad hoc exchanges of information between you and your delegated entity?

Think outside the box when developing your monitoring and oversight strategy, especially when it comes to delegates. Ensure that collaborative efforts are outlined at the service agreement level; otherwise, it’s like being in the ocean with no life preserver. If you are not involved at the beginning, you may end up in a regrettable long-term relationship. Insist on being involved at the RFP process. Ask questions: Will the account manager be dedicated to your plan? What are the contents of their canned reports and how are requests for additional information handled? How do current clients feel about this delegate? You check references before you hire an employee — do your homework before diving into a delegated relationship. CMS expects you to protect your members. Make sure any delegate is ready to meet the obligations for which your plan is responsible.