Editor’s Note: BHM doesn’t need to offer delegation, but we do. What better way to show our confidence in our review network? CLICK HERE and let us show how BHM’s delegation options can lower expenses.
Healthcare organizations face challenges regarding reduction of their medical and administrative costs because regulatory and administrative demands are increasing. Payers and providers must evaluate new partner relationships and solutions for work processes and potentially outsource administrative functions in order to offer competitively priced services to patients. Successful delegation requires planning.

Defining Delegation

A formal process by which an organization gives another entity the authority to perform certain functions on its behalf. Although an organization may delegate the authority to perform a function, it may not delegate the responsibility for ensuring that the function is performed appropriately. – NCQA Health Plan Standards

Successful Delegation The process by which the organization contracts with or otherwise arranges for another entity to perform functions and to assume responsibilities covered under these standards on behalf of the organization, while the organization retains final authority to provide oversight to the delegate. – Health Plan Standards

CMS considers delegation a business relationship between the organization and a first-tier entity to perform certain functions that otherwise would be the responsibility of the organization to perform. The organization oversees and is accountable for any functions or responsibilities that are delegated to other entities whether the functions are provided by the first-tier and other downstream entities.

Regardless of the definition, the plan is ultimately held responsible

– An organization may give a delegate the authority to act on its behalf, but the organization remains accountable.

What Drives Compliance Success?

  • Understand delegated entity compliance elements.
  • Communicate the requirements.
  • Document and measure performance against regulatory and contractual standards.
  • Implement monitoring for performance and requirements.
  • Communicate all metrics with the goal of continuous improvement.
  • Timely respond to attestations.

Successful Delegation

Delegation, like any other successful  process, takes discipline, measurable metrics, and maintenance.  The efforts must flow both directions.  For these types of relationships both parties provide feedback and ideas. A surefire path to failure for a healthcare organization is a “set it and forget it” mentality when working with a downstream entity. These steps must guide the overall plan. See the illustration for how each build on the other.

  • Annual Evaluation
    • Assessment of Program and Contract Compliance
  • Performance Monitoring
    • Review of Contract Reporting Requirement Compliance
  • Pre-Delegation
    • Pre-selection Collaboration
    • Successful Contracting
    • Pre-Delegation Evaluation

BHM doesn’t need to offer delegation, but we do. What better way to show our confidence in our review network? CLICK HERE and let us show how BHM’s delegation options can lower expenses.