Independent public-interest evaluations of how systems respect dignity and support agency.
HXR Evaluation
Delegated Medical Groups: Specialist Referral Execution and Escalation
HXR is evaluating whether delegated medical groups execute only the specialist-referral functions actually assigned to them. One bounded cardiology Incident documents conflicting administrative states, transfers/holds, substantial correction work, and delayed reassignment, but current evidence does not establish which of those functions were controlled by a particular medical group. The occurrence therefore supplies context without supporting a group-specific failure finding.
- Evaluation ID
- UXR-EVAL-0016
- Status
- Open — gathering evidence
- Evidence
- supporting incidents
- Last updated
- August 18, 2026
Technical record details
- Canonical analytical title
- Delegated Medical Groups: Specialist Referral Execution and Escalation
- Evaluation type
- Operational Practice
- Benchmark posture
- Developing Evidence
- Blue Score readiness
- Developmental Data Only
- Reform / positive practice
- Not Assessed
- Public revision
- 2
What changed in Public Revision 2
Public Revision 2 adds the bounded cardiology context while explicitly refusing organization-specific blame until delegated function/control is established. This Evaluation is Not Configured for the Phase 1 contribution pilot.
Evaluation scope
Delegated medical-group or IPA performance only to the extent evidence establishes the function delegated to that group. The Evaluation does not assume every group controls every referral or network decision and does not erase the health plan's separate legal responsibility.
Question being evaluated
When a delegated medical group controls part of a specialist-referral pathway, does it execute its assigned referral, authorization, provider-assignment, availability-checking, and escalation functions in a way that produces timely practical access rather than returning coordination work to the patient?
Current findings
What works well or deserves recognition
A medical group can receive credit for prompt availability screening, successful reassignment, preserved urgency, closed-loop handoff, or rapid escalation to the plan when the needed remedy exceeds delegated authority. Correct routing to the actor with real authority is positive performance, not failure.
Difficulties and opportunities to improve
The cardiology Incident documents substantial patient coordination burden and responsibility opacity, but current evidence does not establish that a specific delegated medical group owned the actions producing that burden. No finding is made that Mayflower Medical Group, AltaMed, or another named group failed a delegated duty.
Mixed or conditional findings
Delegation varies by plan, product, specialty, geography, and contract. A group may perform correctly by escalating to the plan if the required remedy is outside its authority, provided the handoff is consequential and preserves continuity. Control must be established before failure or credit is assigned.
Evidence coverage and limits
Current evidence includes the bounded cardiology Incident and contributor testimony as context plus the general California framework preserving plan responsibility despite delegation. Exact delegation documents and transaction-level control evidence remain unresolved.
How the evidence connects
UXR-2026-0805-0001 provides context for this Evaluation but does not currently support a medical-group-specific negative finding because actual delegated control of the disputed steps is not yet established.
Acceptance / benchmark test
For a referral within the group's demonstrated responsibility, urgency and required information are preserved; provider capacity is checked or rapidly corrected; unavailable assignment triggers the appropriate escalation rather than a patient-run search; handoffs preserve context; and the group's work finishes early enough for the overall access requirement to remain achievable.
Next observation or verification
Collect referral/authorization records, assignment notices, availability outcomes, reassignment timelines, handoff records, and organization explanations establishing actual delegated authority. Preserve positive examples where a group detects and resolves or escalates unavailable-specialist problems before patient intervention.