1. IRCCO Compliance education Module 2 ACO Requirements
December 8, 2017
Margaret scavotto and scott gima
Management performance associates

2. IRCCO ACO compliance basics

3. Accountable care organizations definition and Background
ACOs are a group of providers – doctors, hospitals and other providers who are working together to coordinate the care of patients IRCCO is an ACO designed specifically to care for Medicare patients.

4. ACO stats
ACOs cover 10% of the US population (9 million Medicare beneficiaries)
923 ACOs
480 MSSP ACOs
42 2-sided SSP ACOs
ACOs keep evolving, now covering 10% of U.S. population, Modern Healthcare, July 17, 2017

5. ACO goals – Three Part Aim
Better health for individuals
Better health for populations
Lower cost growth or cost savings

6. The requirement 42 CFR § 425.300 Compliance plan.
(a) The ACO must have a compliance plan that includes at least the following elements:
(1) A designated compliance official or individual who is not legal counsel to the ACO and reports directly to the ACO's governing body.
(2) Mechanisms for identifying and addressing compliance problems related to the ACO's operations and performance.
(3) A method for employees or contractors of the ACO, ACO participants, ACO providers/suppliers, and other individuals or entities performing functions or services related to ACO activities to anonymously report suspected problems related to the ACO to the compliance officer.
(4) Compliance training for the ACO, the ACO participants, and the ACO providers/suppliers.
(5) A requirement for the ACO to report probable violations of law to an appropriate law enforcement agency.
(b) ACOs that are existing entities may use the current compliance officer if the compliance officer meets the requirements set forth in paragraph (a)(1) of this section.
(c) An ACO's compliance plan must be in compliance with and be updated periodically to reflect changes in law and regulations.

7. Oig guidance Policies and Procedures Compliance Officer and Committee
Communication (hotline)
Discipline
Investigations and Corrective Action
Auditing and Monitoring
Training and Education

8. Ircco compliance committee
Angie Charlet – Corporate Compliance Officer, Chair
Pat Schou, IRCCO executive director
Ada Bair
Andrew Buffenbarger
Kara Jo Carson
Finance – TBD
IT/HIPAA Security – TBD
Medical Director???

9. Role of the committee
“The OIG recommends that a compliance committee be established to advise the compliance officer and assist in the implementation of the compliance program.” “The compliance committee benefits from having the perspectives of individuals with varying responsibilities in the organization, such as operations, finance, audit, human resources, utilization review, social work, discharge planning, medicine, coding and legal, as well as employees and managers of key operating units.” - OIG Compliance Guidance for Hospitals

10. Committee duties
Develop and implement a strategy to promote the Program to IRCCO Associates, including, but not limited to, compliance training.
Assist the Corporate Compliance Officer in responding to compliance-related issues as they arise, including reporting any probable violation of law to the appropriate law enforcement agency.
Serve as a forum to share information and ideas concerning compliance-related matters.
Evaluate the Program’s effectiveness on a regular basis and make appropriate improvements in its operations.
Analyze IRCCO’s industry environment, the legal requirements with which it must comply, and specific risk areas.
Assess existing P&P that address these areas for possible incorporation into the Compliance Program.
Work with relevant parties to develop standards of conduct and policies and procedures to promote compliance with IRCCO’s Compliance program.
Recommend and monitor, in conjunction with relevant parties, the development of internal systems and controls to carry out IRCCO’s standards and policies and procedures as a part of daily operations.
Promote detection of potential compliance violations (e.g. through a hotline).

11. Ircco’s compliance program: Leadership
Angie Charlet, Corporate Compliance Officer
Compliance Committee
IRCCO Board (includes on Medicare beneficiary)
Medical Director
….and Associate Compliance Officers

12. Compliance program Policy & code of conduct
Clearly delineates IRCCO’s policy and culture of adhering to ethical clinical, business and financial and data integrity practices for accountable care organizations as outlined and defined by CMS Insert link to the policy and code of conduct here

13. Reporting & hotline
Duty to report – participating compliance officers are required to report possible compliance problems relating to IRCCO’s operations of which he/she is aware, including matters reported to the CO by another person.
COs also have an obligation to learn about applicable ACO laws and regulations

14. Reporting & hotline
Angie Charlet, IRCCO Compliance Officer Backbone Road East, Princeton, IL 61356
IRCCO anonymous compliance online report form:

15. What to report Beneficiary inducements Inaccurate data
HIPAA breaches involving ACO data
Excluded or unlicensed providers
False claims or kickbacks that implicate ACO data or transactions
Cherry picking (avoidance of at-risk beneficiaries)
Use of unauthorized marketing materials

16. Investigations & corrective action
Associate COs and employees are required to cooperate fully with any investigation concerning possible IRCCO compliance problems, any remedial measures taken to correct, or any proactive measures taken to prevent non-compliance
An initial investigation will be conducted by the IRCCO corporate compliance officer to determine evidence of non-compliance
The IRCCO compliance officer will contact legal counsel if necessary
If further investigation is necessary, legal counsel shall be responsible for directing the investigation
The use of outside consultants may also be used if necessary

17. Investigations & corrective action
IRCCO Associates shall submit relevant evidence, notes, and findings to legal counsel
The IRCCO compliance officer will prepare a written report which (1) defines the nature of the problem, (2) summarizes the investigation process, (3) makes factual findings, (4) summarizes recommendations for corrective action to be taken

18. Compliance as an element of employee performance
Adherence to the IRCCO compliance program is a condition of employment for ICAHN employees
IRCCO Management has the responsibility to fairly and consistently discipline IRCCO employees who violate the compliance program
Associate level compliance programs should also require employees to adhere to the IRCCO compliance program as a condition of employment
Adherence to the IRCCO compliance program is also a condition of participation in IRCCO and is subject to penalties including termination from IRCCO

19. Compliance as an element of employee performance - conduct
Participation in or authorization of actions that violate Federal and/or State laws and regulations, the Compliance Program (including the Code of Conduct), or IRCCO policies and procedures.
Failure to report a violation or suspected violation of Federal and/or State laws or regulations, the Compliance Program, or IRCCO policies and procedures.
Actively or passively encouraging, directing, facilitating or permitting non-compliant behavior.
Failure by a violator’s manager to detect and report a compliance violation, if such failure reflects inadequate supervision or lack of oversight.
Refusal to cooperate in an investigation of a potential violation.
Retaliation against an individual for reporting a compliance violation.

20. Compliance program – periodic updates
IRCCO will keep its compliance program in compliance with any changes in laws and regulations
Periodic updates will be issued as necessary to address future changes in ACO laws and regulations relevant to IRCCO

21. calculation of shared savings
IRCCO operates as a one-sided ACO risk model under Track 1
IRCCO is not accountable for shared losses
The MSR (minimum savings rate) is a function of the # of beneficiaries annually assigned to IRCCO
Payments to IRCCO are based on meeting or exceeding the savings rate, meeting minimum quality performance standards and maintaining eligibility to participate in the shared savings program

22. IRCCO ACO requirements

23. distribution of shared savings
Category
Percentage of Savings
Justification
Reinvestment into the organization
15%
Provide funds for research and development such as pilots to test new care transition protocols, chronic disease monitoring program or smart phone application via remote monitoring or expand information technology systems.
Hospital and Physician Participants
50%
Distributed equally among participants for their financial support, service and assistance with the ongoing development of IRCCO
Suppliers/Providers Incentives
Improvement in quality services and efficiency of care based on set goals/measures
Members and Leadership
20%
Incentives for leadership to reach organizational goals and shareholder return for members (i.e. ICAHN and other participants that further invest into IRCCO)

24. Reporting quality performance data
IRCCO will publicly report annual quality performance data results for each completed performance year
Data will be reported using CMS issued templates
IRCCO may not modify the template unless otherwise directed by CMS.
Associates must submit quality data on time and certify its accuracy
Associates must notify IRCCO of data inaccuracies immediately

25. Physician Quality reporting system (PQRS)
IRCCO, on behalf of eligible providers, will submit quality measures using the GPRO web interface for the PQRS incentive under the Shared Savings program
Eligible providers/professionals may only participate under their IRCCO participant TIN as a group practice
The PQRS incentive is equal to 0.5 percent of the IRCCO’s eligible professionals’ total Medicare Part B Physician Fee Schedule allowed charges for covered professional services furnished for the calendar years 2012 through 2014.

26. Federal government’s right to audit records
IRCCO will maintain all books, contracts, records, documents and other evidence of a period of 10 years from the final date of the agreement period or from the date of completion of any audit, evaluation or inspection
Exceptions if CMS determines there is a special need to retain records or if there is a termination, dispute or allegation of fraud or similar fault against IRCCO which may lead to retain records for an additional 6 years
Associates will keep IRCCO records for 10 years and cooperate with audits

27. Beneficiary assignment
Beneficiaries are assigned to IRCCO by CMS (not IRCCO)
Beneficiaries are free to exercise choice in determining where to receive health care services

28. IRCCO participant, provider and supplier Management

29. Meaningful commitment
IRCCO requires meaningful commitment from each participant, provider and supplier
Meaningful commitment can be shown by agreeing to comply and implement IRCCO’s processes and by being accountable for meeting IRCCO’s performance standards for these processes
Associates will complete and comply with attestations

30. Updated participants, providers, suppliers and TINs
IRCCO is required to submit a list of all Participants and their TINs to CMS annually
All providers are required to notify IRCCO of a practitioner’s or physician’s termination/separation within 15 days
All providers are required to notify IRCCO of any additions or deletions of a provider billing through any provider’s TIN within 15 days

31. IRCCO beneficiaries

32. Minimum number of beneficiaries
IRCCO must have at least 5,000 beneficiaries (there are 20,000+)
IRCCO is required to submit a list of all Participants and their TINs to CMS annually
All providers are required to notify IRCCO of a practitioner’s or physician’s termination/separation within 15 days
All providers are required to notify IRCCO of any additions or deletions of a provider billing through any provider’s TIN within 15 days

33. Patient centeredness
IRCCO’s board has adopted a focus on patient centeredness, which is integrated into practice by leadership and management
Patient centeredness includes:
The promotion of evidence–based medicine
The promotion of patient engagement
The use of internally reported quality and cost metrics to evaluate and improve IRCCO’s performance
The coordination of care across the continuum of care
Associates will promote patient-centeredness practices

34. Beneficiary notification
IRCCO participants will notify beneficiaries at the point of care that the Provider is participating in an ACO Shared Savings Program
Participants must post IRCCO provided beneficiary notification signs that state Provider participation in the Shared Savings Program
IRCCO also provides standardized written notices regarding participation in the Shared Savings Program.
The written notices include, if applicable, data opt-out
Written notices must be available where beneficiaries receive primary care services

35. Patient experience of care survey
Press Ganey conducts an annual patient experience of care survey
The survey is a standardized survey that measures patient perceptions of care

36. IRCCO data

37. Data submission & certification
All participants, providers, suppliers, individuals and entities providing ACO related services must submit all data and information, including quality measures data to IRCCO
CMS specifics the form and manner of the data submission
IRCCO is required to certify the accuracy, completeness and truthfulness of the data and information
In turn, IRCCO requires all participants, providers and suppliers to attest to the accuracy, completeness and truthfulness of the data and information that is submitted to IRCCO

38. EHR use
CMS encourages the use of a robust EHR infrastructure and EHR adoption is heavily weighted in the quality performance score
IRCCO has taken the following steps to encourage implementation of EHR:
Xxxxx
xxxxxx

39. Data sharing
As a condition of receiving aggregate data reports from CMS, IRCCO observes relevant statutory and regulatory requirements related to the use of data and the confidentiality and privacy of PHI
IRCCO has a HIPAA program in place that includes:
HIPAA Privacy polices and procedures
HIPAA Security polices and procedures
HIPAA Breach Notification polices and procedures
Associates will comply with HIPAA and with IRCCO’s data sharing policies

40. Data sharing – beneficiary opt out
IRCCO will only use beneficiary data under the following conditions:
The beneficiary name appears on the preliminary prospective assignment list
Or if the beneficiary received a primary care service from an IRCCO participant
The beneficiary was notified in writing of how IRCCO intends to use identifiable claims data to improve quality of care and coordinate care to the beneficiary
The beneficiary did not decline having his/her claims data shared with IRCCO

41. Minimum necessary data
When using or requesting PHI, IRCCO will make reasonable efforts to limit PHI to the minimum necessary
Minimum necessary means the use of the minimum necessary to accomplish the intended purpose of the use, disclosure or request
Associates will follow the minimum necessary rule when transmitting data to IRCCO.

42. IRCCO policies

43. Marketing
IRCCO is committed allow beneficiaries to take advantage of all of their benefits
IRCCO does not market itself as “endorsed” by Medicare
Marketing materials include but not limited to:
Brochures, advertisements
Outreach events
Letters to beneficiaries, mailings
Web pages, social media
Data sharing opt out letters
IRCCO can only use materials and activities that have been provided and therefore, pre-approved by CMS
Any IRCCO developed marketing materials and activities must be pre-approved by CMS before use

44. Beneficiary inducements
The Anti-Kickback Statue and Beneficiary Inducement Law (42 U.S.C. 1320a-7a(a)(b))prohibit offering or giving anything of value to beneficiaries to induce them to obtain services from a IRCCO provider
Providing items or services for free or below fair market value is also prohibited
A Beneficiary Inducement Waiver is allowed for items or services offered to patients that promote preventive care and increase adherence to follow-up treatment
Associates will follow IRCCO’s beneficiary inducements policy and disclose inducements to the IRCCO Corporate Compliance Officer

45. Avoidance of at-risk beneficiaries
IRCCO is not allowed to avoid at-risk beneficiaries or engage in practices that could prevent or deter at-risk beneficiaries from participating in IRCCO or prevent them from obtaining care from an IRCCO provider
At-risk beneficiaries include, but not limited to the following:
Has a high score on the CMS-HCC risk adjustment model
Had two or more hospitalizations or ER visits in a year
Is covered by Medicare and Medicaid (dual eligible)
Has a high utilization pattern
Has on or more chronic conditions
Has a recent or active diagnosis that can lead to increased cost
Is covered by Medicaid due to a disability
Has a mental health or substance abuse diagnosis
Associates will not participate in cherry picking

46. Employee and contractor screening
All participants, providers and suppliers are obligated to screen their own employees, contractors and other parties
All participants, providers and suppliers will attest at least annually the following:
Screens are conducted on employees, vendors, contractors, board members and volunteers
It conducted required screens pre-employment and monthly (or per another frequency acceptable to IRCCO)
It notifies IRCCO of any identified exclusions, license lapses or other screening incidents
It routinely audits a sample of records to verify all screens are conducted

47. Employee and contractor screening
The screens to be conducted include the following:
Criminal background history
Office of Inspector General (OIG) Exclusion List
Government Services Administration (GSA) Suspension and Debarment List
State of Illinois Medicaid Program Exclusion List
Licensure
I-9 verification

48. Referrals and cost shifting
IRCCO does not base the participation of Participants, Providers and Suppliers on referrals of beneficiaries who are not assigned to IRCCO
IRCCO does not require that beneficiaries can only be referred to IRCCO Participants, Providers and Suppliers
Associates will adhere to IRCCO’s referrals and cost-shifting policy

49. Duplicate payments
Beneficiaries may be assigned to other ACOs or shared savings programs including dual-eligible initiatives
There can be no duplication in payments for these beneficiaries
CMS, not IRCCO, is responsible for identifying duplicate payments

50. records
Participants, Providers and Suppliers are responsible for the following compliance and MSSP documentation:
Meaningful commitment
Attestations
Efforts to promote patient centeredness practices
Efforts to enforce adherence to patient centeredness practices
Participation Agreement between IRCCO and Participants, Providers and Suppliers
Update list of Participants, Providers and Suppliers, related TIN and NPI numbers

51. HIPAA
As a business associate to the IRCCO Associates, IRCCO is devoting necessary resources to ensure compliance with the HIPAA Privacy, Security and breach Notification Rules (HIPAA rules)
Associates are also required to comply with the HIPAA rules and will be asked at least annually to attest to their compliance with the HIPAA rules

52. False claims
The federal False Claims Act prohibits the submission of false, fraudulent or misleading claims to government payors, such as Medicare, Medicaid or TriCare
ACO related issues include the following:
Providing information known to be false
False certification of quality or other ACO data submissions
False annual MSSP compliance or data accuracy certifications
False documents or reports (application materials, network filings)
Failure to return overpayments

53. False claims
All IRCCO Participants, Providers and Suppliers (Associates) are responsible for:
Producing and maintaining complete and accurate documentation of appropriate medical records
Submitting complete and accurate charges for all medical goods and services provided to beneficiaries
Ensuring submitted claims are in compliance with all applicable requirements
Associates who believe IRCCO has submitted improper claims to or received payments to which it is not entitled from any federal healthcare program shall report such information immediately to the IRCCO Compliance Officer

54. kickbacks
The Federal Anti-Kickback Statute prohibits any remuneration to induce or reward referrals of items or services that are reimbursable by Medicare or Medicaid.
IRCCO Policies cover the following issues:
Gifts to and from referral sources
Beneficiary inducements
Avoidance of at-risk beneficiaries
Non-physician contracts
Prohibition on certain required referrals and cost shifting
Physician contracts
Physician self-referrals
Gainsharing

55. kickbacks
There are five waivers related to Shared Savings Programs that waive fraud and abuse penalties under certain circumstances, these include:
ACO pre-participation waiver (n/a at this time)
ACO participation waiver
Shared savings distribution waiver
Physician self-referral (Stark) law waiver
Patient incentives waiver
Associates will comply with IRCCO’s waiver and kickbacks policies

56. auditing
As a business associate to the IRCCO Associates, IRCCO is devoting necessary resources to meet the requirements of an ACO compliance program which also includes periodic auditing of ACO related risk areas
Associates are also required to have established a working compliance program that includes the auditing of compliance risk areas related to ACO risk areas including but not limited to false claims and data accuracy
Associates will be required to at last annually attest to their auditing activities