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Compliance and How It Fits in the ACO
Angie Charlet, DBA, MHA, RN Dir. of Quality/Education, Compliance for ICAHN, ACO
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AGENDA Compliance Requirements in an ACO Audit Review
Policies for Robust Program Success Credit goes to Management Performance Associates (our consultants)
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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) (1) 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. (2) An ACO's compliance plan must be in compliance with and be updated periodically to reflect changes in law and regulations.
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OIG Guidance Policies and Procedures Compliance Officer and Committee
Communication (hotline) Discipline Investigations and Corrective Action Auditing and Monitoring Training and Education
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Compliance Program Infrastructure:
Governance & Structure Policies and Procedures Training and Education Auditing and Monitoring Complaints and Communication Investigations, Corrective Action and Discipline Review and updates
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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
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Committee duties Develop and implement a strategy to promote the Program to ACO 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 ACO’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 ACO’s Compliance program. Recommend and monitor, in conjunction with relevant parties, the development of internal systems and controls to carry out ACO’s standards and policies and procedures as a part of daily operations. Promote detection of potential compliance violations (e.g. through a hotline).
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Governance and Structure
Completed Compliance Officer & Committee job description Medical Director Job description Board Resolution Compliance Program Policy Written board reports Vet Medicare beneficiary on the board Relationship with health care legal counsel Establish how ACO will communicate with Participants and providers/suppliers (monthly calls) Quarterly Compliance Committee meetings ACO board composition and control policy ACO leadership and management structure policy Board conflicts of interest policy
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Governance and Structure cont.
What’s next? Code of Conduct Live board reports Screen directors for conflicts Document meaningful commitment
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Policies and Procedures
Compliance Program Policy Questions and Complaints Administrative Operating Requirements Shared savings (and losses) qualification Notifying CMS of new/removed Participants and Providers/Suppliers Public reporting and transparency Repayment mechanism Waivers Antitrust QM Collection and Reporting
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Policies and Procedures
Beneficiaries and Patient Centeredness Participant and Provider/Supplier Management (drafting stage) Participant and Provider/Supplier requirements Meaningful commitment Reporting/hotline HIPAA Privacy HIPAA Security HIPAA Breach Notification HIPAA and Social Media
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Policies and Procedures
Distribute Compliance Program and Code Code of Conduct Quality Assurance Billing and Claims Submission (Participants, Provider and Suppliers) Referrals Kickbacks Stark Beneficiary Inducements Avoidance of at-risk beneficiaries (cherry picking) Referrals and cost-shifting Employee and Contractor Screening
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Policies and Procedures
Records Marketing Data Submission Certification Sharing Data Use Agreements HER use Minimum necessary
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Training and Education
Participants and Provider/Suppliers Compliance Officers Participant Board Members (to be done by local compliance officers) CO should complete attestation of completion to ACO
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Auditing and Monitoring
Press Ganey (or other vendor) patient experience of care survey Minimum of quarterly analysis of claims data (7 per provider to identify areas for improvement) Review of QM accuracy as part of ACO on-site audits Review quarterly data for trends to identify potential QM inaccuracies/variations to investigate HIPAA Security Risk Analysis completed
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Auditing and Monitoring
Obtain attestations Annual review of ACO compliance program Review OIG work plan (most recent from October 2017), identify risks, audit those risks Use peer to peer audits, ACO officer completing audits, or self-audits certified by member participants, to address ACO risk areas
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Suggested Audit frequency
Governance Frequency Verify board resolution is in place Annual Board focus and involvement CCO qualifications, job description, reporting Anonymous Compliance Committee Survey ACO governing body documents, composition, control and duties ACO board Medicare beneficiary COI Board conflicts of interest vetting process Leadership and management structure Medical director meets requirements
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Suggested Audit frequency
Participant and Provider/Supplier Management Frequency Meaningful commitment Annual Adherence to patient centeredness processes ACO participants do not participate in another MSSP New P and P/S receive CMS participation agreement Each Participant ahs a CMS participation agreement Exclusivity of Participant TINs Verification of NPIs and TINs Monthly ACO develops claims audit tool for use by P and P/S TBD # of PCPs Monthly or Quarterly Identification of new/removed P and P/S P and P/S accurately capturing covered lives/beneficiaries meet requirements Quarterly Verification of Provider and Supplier TINs
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Suggested Audit frequency
ACO requirements Frequency Documentation in support of CMS participation agreement Annual Identification of ACO changes requiring CMS notification Monthly ACO’s status as an State legal entity is up to date Shared savings distributed in accordance with CMS participation agreement and 3-part aim When applicable, verify repayment mechanism CMS participation agreement supplemented as necessary Adherence to CMS participation agreement Antitrust compliance (if applicable) Tax exempt status Posting, accuracy, and adherence to CMS MSSP Public reporting guidance Waiver requirements (if/when applicable) Savings (when applicable, and losses) criteria are met
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Suggested Audit frequency
ACO Compliance Basics Frequency Compliance Program Policy and Code of Conduct updates Annual 7 compliance program elements, Investigation procedures Complaints and response Review compliance reports for trends Annual or Quarterly Compliance as part of employee performance Compliance program updates were implemented Compliance Program and Code were distributed Anonymous employee surveys ACO internal assessment of cost and quality of care Quarterly Analysis of beneficiary and provider complaints
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Suggested Audit frequency
Data Frequency Accuracy of data used for beneficiary assignment (Physician NPI, claims for primary care services HCPCS codes) Annual Data policies Data accuracy, verification of data certification Monthly or Quarterly PQRS data accuracy Data sharing: HIPAA Security Risk Analysis; audit P and P/S compliance with HIPAA Minimum necessary data was used Degree of EMR adoption Accuracy of QM data; quality performance ACO data submission/certification and of data submission/certification by P and P/S Analysis of specific financial and QM data reported by the ACO as well as aggregate annual and quarterly reports Quarterly and Annually
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Suggested Audit frequency
Beneficiaries Frequency Beneficiary notification Annual Documentation of beneficiary opportunity to decline data sharing; honoring elections to decline; adherence to DUA Verify patient experience of care survey vendor is CMS certified; review survey results Gifts/services for beneficiary inducements Minimum # of beneficiaries Monthly or Quarterly Patient centeredness processes
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Suggested Audit frequency
Risk Areas Frequency Kickbacks/Referrals Annual Adherence to Records policy Avoidance of at-risk beneficiaries (review data for trends suggesting cherry picking Quarterly Referrals/cost shifting Marketing materials/practices HIPAA audit plan Monthly, Quarterly and Annually Verify QM data is accurate (medical records review; audit quality performance; monitor minimum attainment level) Monthly or quarterly Audit for duplicate payments Monthly or Quarterly Employee, director, contractor screens Monthly Billing and claims/false claims audits Coding and medical necessity peer to peer audits* * One Option is for ACO to coordinate audits, or a peer-to-peer audit program for a year and for all new ACO providers, then transition to a checklist/attestation. If provider does not send in attestation, ACO sends in their own auditor and charges an audit fee.
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Member Obligations/Attestations
Hotline in place Hotline # provided to ACO Compliance officer, Privacy officer and security officer information provided to ACO Compliance committee Beneficiary assignment Patient centeredness Meaningful commitment TIN exclusivity Non-participation in other MSSP Participation agreements
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Member Obligations/Attestations
Compliance board resolution Regular compliance reporting to their Boards Conflicts of interest policy Compliance training program Compliance audits (including billing) HIPAA compliance program QAPI program
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Member Obligations/Attestations
Accuracy of ACO data submissions to ACO in accordance with federal requirements Excluded provider screens conducted monthly License verifications and background checks Use of ACO/CMS approved marketing materials False claims/claims submission compliance policies False claims/claims submission auditing and monitoring Medical necessity auditing and monitoring
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Complaints and Communication
Online complaint form established Compliance Questions and Reports policy updated Publicize reporting options
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Investigations, Corrective Action, and Discipline
Compliance Reports and Questions Policy updated Compliance Log Form created Compliance Report Intake Form created Provider agreements provide ACO discretion to take action for non-compliance, up to and including removal from the ACO Tell Participants, Providers and Suppliers about reporting options and what needs to be reported to ACO
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Investigations, Corrective Action, and Discipline
What should be reported to ACO? Billing Care Excluded providers/unlicensed providers Documentation/data accuracy False claims Patient experience of care/failure to meet patient centeredness ACO policy violations Provider RAC audit findings that may violate ACO policies Failure to achieve 3-ppart aim
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Review and Updates Ongoing:
Review OIG work plans, ACO guidance, OCR press releases, and other compliance updates on an ongoing basis; incorporate into the compliance program
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Biggest Risks “Notwithstanding any arrangements between or among an ACO, ACO participants, ACO providers/suppliers, and other individuals or entities performing functions or services related to ACO activities, the ACO must have ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of its agreement with CMS.” 42 CFR (c)
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Biggest Risks Accuracy of data submitted to CMS Quality Assurance Adherence to patient centeredness processes Meaningful commitment from members Measuring achievement of the three-part aim of improving care delivery, improving health, and reducing growth in costs through improvement ACO’s biggest challenge is verifying that its members adhere to the compliance program.
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Addressing Risks Audits How does ACO tackle these risks? Policies
Training Audits Attestations
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Tools and Resources
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P&P Manual Copy of our manual…..
Feel free to call with questions/changes etc.
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Training Webinar/Slide Deck
This was our training program from our consultants. Should you have any questions or need assistance feel free to reach out to either Margaret or Scott as well as myself. Management Performance Associates Margaret Scavotto, CEO Scott Gima, COO Exec. VP Compliance , ext 21
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