The purpose of the Pre-Delegation Audit is to fully assess a proposed delegate’s capacity to manage and perform the delegated function in accordance with state and federal laws, rules, and regulations, accreditation organization standards and CarePlus requirements. The pre-delegation audit is conducted prior to the effective date of delegation. It consists of a desktop review of documentation, review of the proposed delegate’s provider downstream agreements and an on-site visit, if necessary. During the pre-delegation audit proposed delegates are notified of any reporting requirements and frequency, the process by which performance will be evaluated and the remedies available to CarePlus if obligations are not fulfilled. Pre-delegation audits are conducted by CarePlus in collaboration with our parent company, Humana, when applicable.
Collected information for the various delegated functions includes, but may not be limited, to the following:
** Policies and procedures
** Program descriptions and work plans
** Forms, tools, systems and reports
** Sub-delegation agreements
** Letters of Accreditation
** Financial Solvency
** File Audit
CarePlus requires all delegated providers to enter into a written, mutually agreed upon contract. The Delegation Services Addendum and applicable attachments at a minimum includes the following provisions: (i) delineates the duties and responsibilities of both the Plan and the delegated provider; (ii) outlines the services to be performed by the delegated provider, including reporting responsibilities; (iii) specifies that performance of the delegated provider is monitored on an ongoing basis by the Plan; (iv) retains the CarePlus’ right to approve, suspend and terminate individual practitioners, providers and sites where it has delegated decision making; (v) the credentials of medical professionals affiliated with the delegated provider will be either reviewed by CarePlus or the credentialing process will be reviewed and approved by CarePlus and will be subject to auditing on an ongoing basis; (vi) if CarePlus delegates selection of providers to the delegated provider, written arrangements must state CarePlus retains the right
to approve, suspend, or terminate any provider selected by the delegated providers; (vii) must comply with all applicable Medicare laws, regulations and CMS instructions; and (viii) provide for revocation of the delegation activities and/or other remedies in instances where the delegated provider is not performing satisfactorily. Grids within each delegation attachment are designed to delineate the actual functions and detail the requirements in each delegated arrangement, and may be tailored to define each agreement.
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