October 02, 2019
During a session at Health Care Quality Congress 2019, Ambria Moore, BA, PMP, and Denise Parker, both delegate oversight project managers at BlueCross BlueShield (BCBS) of Tennessee, provided tips and techniques for professionals to keep organizations engaged, accountable, and in an ongoing state of readiness.
Ms Moore and Parker kicked off the session with a company overview. They said that BCBS of Tennessee has been serving its members for over 70 years. The population they serve include 3.5 million members, 11,000 employer groups, and six local offices and service centers across the entire state. Further, the BlueCross Health Foundation has given $90 million in grants and scholarships since 2005. The session presenters also highlighted that BCBS of Tennessee has been recognized for various awards, and have a wide range of accreditation, compliance surveys, and audits associated with the organization.
The session presenters highlighted their Delegate Oversite program that the company launched. They explained that their program further supports the power of partnerships. Their program encompasses the following:
- Quality management;
- All lines of business;
- Information security risk management;
- Pharmacy management;
- Internal audit;
- Vendor management; and,
- Legal matters.
The program has evolved since 2001, according to the presenters. Between 2001-2004 the centralized program was implemented, and over these years URAC standards were added as well as NCQA standards. Between 2005-2008 specialty pharmacy contracts were added as well as wholly owned subsidiaries. During this time frame the program was awarded the Health Ethics Trust Best Practice award. Next from 2009-2013, contracts that involved data exchange were added, and they removed dental services. Finally, from 2016-2019, hybrid contracts including vendor and provider services were added, and contracts involving data exchange limited to include PHI and PII data only were included.
Ms Moore and Parker then told the audience what exactly makes their program innovative. They explained that they support all lines of business. The program focuses on accreditation standards, state and federal guidelines, as well as contractual requirements. Additionally, the program provides oversight of vendors that make contact with members, and/or have access to their data. Finally, the program has unique contract addendums that allows BCBS to provide ongoing oversight throughout the contract life cycle.
The session presenters gave attendees a roles and responsibilities contract checklist. Included in their checklist was:
- Accreditation and regulatory requirements;
- Seven elements of compliance program;
- Termination and revocation language;
- Sub-delegation requirements;
- Record retention;
- Service addendums;
- Information security requirements; and.
- Risk rankings.
Additional tips provided were for technical improvements in partnerships. They explained that it is important to track vendor activity, contract status, and internal and external primary contacts. Additionally, they said there should be specific designations, accreditation types, and audit types assigned, and to update systems in real-time in order to ensure accurate reporting. Finally, they recommended generating 13 standard report with the click of a single button.
The session speakers also suggested risk stratification based on their experiences at BCBS. They explained that at BCBS high risk is for regulatory, accreditation or external contractual requirement subject to punitive actions; moderate risk is for failure to meet a BCBST policy that will not result in punitive action form an external party; and low risk is for minimal or no identified risk to the organization but still requires oversight.
They also said that best practices for internal controls include training and ongoing education, quality assurance, as well as inter-rater reliability review.
Finally, they said that best practices to prepare all parties involved for state of readiness include mock audits, gaps analysis, opportunities for improvements, and focus improvement plans.