Delegation

Reversing a long-standing interpretation of Core 17(b), URAC now requires contracts of delegation to mention URAC by name.

The standard reads:

The organization enters into written agreements with contractors that . . . (b) Require that services be performed in accordance with the organization’s requirements and URAC standards. . ..

While the standard's content has not changed, the interpretation has.   Version 2.0 of the Core standards contain the following language in the "Points to Remember": "the written agreement might require sub-contractor compliance with “national accrediting standards that the organization is required to meet.” While that note, on its face, applies to the subdelegation provisions of (g) and (h), it has, for several years, been applied to the primary delegation requirement of (b).  So, this is new.

The subsection is a secondary element of a mandatory standard, so while, under the current scoring system, missing this will cost a URAC applicant points, it will not, by itself, force the applicant into a conditional accreditation status.

HOWEVER . . ., this subsection is proposed as a primary element in the new v. 2.1 standards, so future applicants should expect to get this right or face a conditional accreditation.

It's time to send out those delegation agreement amendments, folks!

The existing standard CR 17 for both Health Plan and Health Network reads:

The organization complies with the Core Standards for any credentialing functions it delegates to another entity. In addition, the organization: (Secondary)
(a) Retains authority to make the final credentialing determination regarding any provider; and (Primary)
(b) At least every three years, conducts surveys of each entity that performs credentialing functions on behalf of the organization. (Secondary)

The proposed revision would change (b), leaving the standard to read:

The organization complies with the Core Standards for any credentialing functions it delegates to another entity. In addition, the organization: [--]
(a) Retains authority to make the final credentialing determination regarding any provider; [M]
(b) At least every three years, conducts an onsite survey of each entity that performs credentialing functions on behalf of the organization or if not conducting the survey onsite, then randomly requested credentialing files are sent to the organization within 24 hours of the request. [4]

As the interpretive information explains, the purpose of this change is "to indicate that in lieu of an onsite survey for conducting oversight of delegated entities for credentialing, the organization may randomly select credentialing files to be sent to it within 24 hours of the request."  

The word "survey", used here and in Core 17 , also dealing with delegation, has always been a bit confusing to some URAC applicants.  This language addresses that confusion head-on, at least for delegation of credentialing.  The term remains undefined for other forms of delegation, however, and I wouldn't be surprised to see the Core delegation standards amended in some future version along the lines of this revision.

I picked up a quick and important tip at the most recent URAC education program that will help make the reviewer's life easier regarding the review of delegation agreements:

Take the time to flag each and every delegation agreement for each and every one of Core 17's eight required elements.  You can do this with a Post-It and a highlighter.  

Remember, this is a mandatory standard, so if you cannot find each of the eight elements in every agreement, go out and amend the agreement right away, especially if it is a primary (underlined) element of the standard. 

As is the case with the other three delegation standards (Core 15-17), URAC proposes no substantive changes to Core 18, Delegation Oversight.  The new standard would read:

The organization establishes and implements an oversight mechanism for delegated functions within the scope of accreditation that includes: (--)
(a) A periodic review (no less than annually) of the contractor’s policies and procedures and documentation of quality activities for related delegated functions; (Wt = 3)
(b) A process to verify (no less than annually) the contractor’s compliance with contractual requirements and policies and procedures; and (Wt = 3)
(c) A mechanism to monitor financial incentives to ensure that quality of care or service is not compromised. (Wt = M)

What is significant about the scoring change is that (c) becomes a mandatory standard.  URAC has attached the "M" designation to a host of new elements that deal with consumer protection, and this is an example of that.  The import of this change is that those staff members charged with delegation oversight now will need to pay particular attention to documenting the method by which they assure that those contractors that have financial incentives in their compensation structures do not compromise quality of care. 

URAC apparently believes (with good reason, in my view), that its current delegation standards are fine just as they are, and therefore proposes no changes in the heart of the four delegation standards, Core 17. This standard outlines the required elements of the contract of delegation between the accredited organization and the contractor:

The organization enters into written agreements with contractors that: (--)
(a) Specify those responsibilities delegated to the contractor and those retained by the organization; (Wt = 2)
(b) Require that services be performed in accordance with the organization's requirements and URAC standards; (Wt = M)
(c) Require notification to the organization of any material change in the contractor’s performance of delegated functions; (Wt = 4)
(d) Specify that the organization may conduct surveys of the contractor, as needed; (Wt = 2)
(e) Require that the contractor submit periodic reports to the organization regarding the performance of its delegated responsibilities; (Wt = 3)
(f) Specify recourse and/or sanctions if the contractor does not make corrections to identified problems within a specified period; (Wt = 2)
(g) Specify the circumstances under which activities may be further delegated by the contractor, including any requirements for obtaining permission from the organization before any further delegation; and (Wt = 4)
(h) Specify that, if the contractor further delegates organizational functions, those functions shall be subject to the terms of the written agreement between the contractor and the organization and in accordance with URAC standards. (Wt = M)

Substantively, the only changes brought about by the scoring system change (other than the fact that the multitude of elements to this standard inevitably gives it morerelative importance than it has in the current system) have to do with which elements are now mandatory. In this regard, there was a major reshuffling of priorities. In the current version the current mandatory elements (I consider any "primary" element in a standard weighted "5" mandatory) are subsections (a), (b), (c), (f), and (g). The proposed revision would make only subsections (b) and (h) mandatory. The transformation of (h) into a mandatory standard should be noted by the contracting department, as this is a frequently missed elements not only by first-time applicants, but by some reaccreditation veterans, as well.

Finally, URAC proposes to help applicants with the following addition to the Interpretive Information:

Examples of “material change” in Core 17(c) for the delegated entity include a change of address, loss or replacement of the senior clinical staff person, and prolonged interruption of services due to any cause (e.g., natural disaster, IT systems down, decrease in staffing, substantive change in delegated processes, etc.)

This is useful, in our view, as a number of our clients have expressed puzzlement about what this clause was intended to address.     

The only changes URAC proposes for Core 16, which describes the required process for reviewing proposed contractors, is in scoring, and even those changes are minor:

Prior to delegating functions to another entity, the organization: (---)
(a) Establishes and implements a process to conduct a review of the potential contractor’s policies and procedures and capacity to perform delegated functions; and (Wt = 3)
(b) Outlines and follows criteria and processes for approving contractors. (Wt = 3)

No changes -- not even in scoring -- are proposed for Core 15. It will continue to read:

The organization establishes and implements criteria and processes for an assessment prior to the delegation of functions. (Wt = 3)

URAC has made a housekeeping change to Core 18 in v. 2.1, a 3-weighted standard.  The stem of the standard has changed from:

The organization implements an oversight mechanism for delegated functions that includes:

to

The organization establishes and implements an oversight mechanism for delegated functions within the scope of accreditation that includes:

To my eye, the addition of "establishes and" doesn't add much other than a tip of the hat to making sure you have a formal process that is memorialized in a P&P.  The more significant change is the addition of "within the scope of accreditation".  This is not a policy change -- URAC has always limited the requirements of its delegation standards to the scope of the accreditation.  It has done so, however, in the interpretive guide.  This looks like an attempt to be crystal clear, in the body of the standard, that the scope of your accreditation application limits the scope of the delegation requirements.

So, if you are a health plan, for example, that delegates network functions to contractors, but are applying only for Health Utilization Management accreditation, you need not address those delegation relationships in your HUM application.

No language has changed in Core 17 from version 2.0 to 2.1.  However, subsection (b), which requires that a delegation agreement mandate that the contractor perform the delegated functions in accordance with the organization's requirements and with URAC standards, has been changed from a secondary element to a primary element.  This is a more significant change than it might appear to the uninitiated in the URAC scoring system. 

The change would be rather minor if Core 17 were not a mandatory standard, with a weight of 5.  However, because the standard is mandatory, this change is quite important.  In a nutshell, by making this change, URAC is saying that your delegation agreements must have this clause or else you cannot achieve full accreditation.  This is true because, while you can miss a secondary element of a mandatory standard and still receive a score of 3 out of 4, missing a primary element forces your score for that standard down to a 1 out of 4, which is below the threshold of 2 for meeting a mandatory standard.  

So, go back and check all your delegation agreements (as well as your P&P governing delegation agreements, since, as I said in another blog, your P&P is as important as your behavior when it comes to complying with URAC standards). 

One other note -- remember that language requiring compliance with your requirements is not enough -- compliance with URAC standards (or "applicable accreditation standards") must also be required by your contract.  Compliance with another accreditation body's standards (such as NCQA or AAAHC) simply won't do.

Version 2.1 of Core amends subsection (a) of Core 16, a primary element of this 4-weighted standard. The original language was:

Prior to delegating functions to another entity, the organization: (N/A)

(a) Conducts a review of the potential contractor’s policies and procedures and capacity to perform delegated functions; (Primary)

The new, v. 2.1 language now reads:

Prior to delegating functions to another entity, the organization: (N/A)
(a) Establishes and implements a process to conduct a review of the potential contractor’s policies and procedures and capacity to perform delegated functions; (Primary)

This seems to echo what I said in an earlier blog, that even if you are doing something correctly, URAC prefers that you also have a policy and procedure that instructs you to do it correctly. In this case, this means that not only must you conduct a review of the potential conctractor's P&Ps and ability to perform the tasks you delegate to them, you must have that review be part of a process that you've implemented. This assures URAC that it is not a one-time thing, but that, instead, you'll be conducting these reviews on all future contractors.

As a practical matter, this means that your documentation must not only include evidence that you've conducted such reviews on your contractors, but also have a policy and procedure that clearly outlines that required process.