What is Delegation Oversight and Monitoring

Delegation monitoring and oversight is conducted by CarePlus in collaboration with our parent company, Humana. This is the formal process by which CarePlus monitors the performance of a delegated provider and  ensures  compliance  with  the  required  state  and  federal  laws,  rules,  and  regulations,  accreditation organization standards and CarePlus requirements, as well as, operational performance requirements and enforcement of the written delegation agreement to ensure services have been provided in accordance to the agreed upon terms. This process encompasses (i) monitoring and analyzing routine periodic reports and quality indicators and (ii) audits, which refers to an in-depth assessment of the delegated provider.

The delegated entities are required to report on specific quality indicators, depending on the delegated function.  These  indicators  are  communicated  to  the  entity  and  clearly  outlined  within  the  delegation amendment.  Reports  to  and  from  the  delegate  and  their  reporting  frequencies  can  be  on  an  annual, monthly or quarterly basis. Reports are reviewed for timeliness, accuracy and compliance with the agreed upon delegation requirements.

Audits are conducted on annual basis utilizing a delegation audit tool. The tool outlines the indicators established for the auditing and monitoring of the provider. This occurs at a minimum annually from the last oversight review. Reviews include, but may not be limited to, the following:

** Policies and Procedures
** Program descriptions and work plans
** Forms, tools, systems and reports
** Sub-delegation agreements (if applicable)
** Letters of accreditation
** Financial solvency
** File audit

Humana,  our  parent  company,  performs  the  combined  oversight  audits  on  delegates  that  are  shared between CarePlus and Humana. CarePlus performs the oversight audit on delegates unique to CarePlus utilizing Humana’s audit tool for the respective delegated function to ensure a consistent auditing process.

CarePlus retains the decision-making authority in the evaluation of delegated entities.

A corrective action plan (CAP) shall be imposed should the delegated provider fail to perform – in whole or in part – the required elements of the delegated function. The CAP should contain the issues that have been identified, the actions to be taken by the delegate and the timeframes for improvement. A report of audit findings and/or CAPs is prepared and presented to Delegated Services Committee. Audits may be conducted more frequently than once a year if it is necessary to closely monitor a delegated provider’s performance.