Development and Implementation of Corporate Compliance for FQHCs - PowerPoint PPT Presentation

May 25, 2016 Development and Implementation of Corporate Compliance for FQHC’s Peak Performance Physicians, LLC Louisiana Primary Care Association T HE C OMPLIANCE I NSTITUTE 1 May 25, 2016

Compliance • Compliance does not get you into May 25, 2016 trouble; • It keeps you out of trouble. Peak Performance Physicians, LLC 2

LPCA Compliance Syllabus 1. Introduction to Compliance ‐‐ Power Point ‐‐ MARCH 30 a. OIG b. OCR May 25, 2016 2. Getting Started – APRIL 27 a. Compliance Officer – Role and Definitions b. Code of Conduct – Board Adoption c. Risk Assessment – “top five areas” d. Compliance Hotline Peak Performance Physicians, LLC 3. Conditions for Coverage – MAY 25 a. FQHC b. RHC 4. 340 b Plan – JUNE 29 5. Human Resources – JULY 27 a. Exclusions b. Licensure/Certifications c. Education 6. Financial Relationships ‐‐ AUG 31 a. Fraud and Abuse b. False Claims Act c. Stark Laws 7. Data Integrity – HIPAA ‐‐ SEPT 28 3 a. HIPAA I b. HIPAA HiTech

Compliance Institute • A cooperative between Peak Performance May 25, 2016 Physicians and Louisiana Primary Care Association Peak Performance Physicians, LLC • Our main goal: • To assist you in establishing an effective Compliance Plan at your facilities 4

Presentation Goals • There are 19 Key Health Center Program Requirements. See: http://www.bphc.hrsa.gov/about/requirements/index.html May 25, 2016 • Requirements are divided into four categories: • A. Need • B. Services Peak Performance Physicians, LLC • C. Management & Finance • D. Governance • We will discuss each of these Program Requirements. 5

Why Compliance Program? • Most all of the Compliance Books, Seminars, and other presentations always start with all the punishments…. May 25, 2016 • We think that compliance is doing what is right. Peak Performance Physicians, LLC • We further think that most all employees and employers want to a good job, and to do their jobs effectively and legally. 6

What is a Compliance Program? • A Compliance Program is an effective, practical and integrated management tool that establishes clear and defined goals and May 25, 2016 procedures designed to create a culture of compliance, reduce the occurrence of mistakes and prevent intentional violations of the applicable health care statutes and regulations. Peak Performance Physicians, LLC • An effective Compliance Program provides you and your employees with tools for acting ethically and for maintaining compliance with applicable laws and regulations. 7

Compliance Goals • Goal: to create a “Culture of Compliance” throughout the FQHC by showing a commitment from the top and enforcing May 25, 2016 compliance standards throughout the entity. • Benefit: by focusing attention on processes and reinforcing clinical standards through audits and training, Attendees can Peak Performance Physicians, LLC maintain and improve its high quality of care. • Benefit: by minimizing potential compliance errors; detecting and correcting any errors that do occur, Attendees will help keep such errors from becoming significant and crippling civil fines and penalties. 8

Key Elements for the Compliance Plan • Conducting internal monitoring and auditing; • Implementing compliance and practice standards; May 25, 2016 • Designating a compliance officer or contact; • Conducting appropriate training and education; Peak Performance Physicians, LLC • Responding appropriately to detected offenses and developing corrective action; • Developing open lines of communication; and • Enforcing disciplinary standards through well ‐ publicized guidelines. http://oig.hhs.gov/authorities/docs/physician.pdf 9

Tools for Compliance • Utilizing the Compliance Officer and Compliance Committee as mechanisms for clarifying requirements and reporting potential May 25, 2016 misconduct; • Reviewing and understanding your written policies and procedures; Peak Performance Physicians, LLC • Maintaining effective lines of communication with management and other staff members; and • Participating in training and education opportunities. 10

Next Steps • Appoint Compliance Officer • Establish a Coding Hotline May 25, 2016 • Review Compliance Guidance • Review Compliance Plan Peak Performance Physicians, LLC • Review Areas of Greatest Risk • Perform GAP Analysis • Establish a “Code of Conduct” 11

Overview • There are 19 Key Health Center Program Requirements. See: http://www.bphc.hrsa.gov/about/requirements/index.html May 25, 2016 • Requirements are divided into four categories: • A. Need Peak Performance Physicians, LLC • B. Services • C. Management & Finance • D. Governance 12

A. NEED • 1. Needs Assessment 13 Peak Performance Physicians, LLC May 25, 2016

B. Services • 2. Required and Additional Services • 3. Staffing Requirement May 25, 2016 • 4. Accessible Hours of Operation/Location • 5. After Hours Coverage Peak Performance Physicians, LLC • 6. Hospital Admitting Privileges and Continuum of Care • 7. Sliding Fee Discounts • 8. Quality Improvement/Assurance Plan 14

C. Management and Finance • 9. Key Management Staff • 10. Contractual/Affiliation Agreements May 25, 2016 • 11. Collaborative Relationships • 12. Financial Management and Control Policies Peak Performance Physicians, LLC • 13. Billing and Collections • 14. Budget • 15. Program Data Reporting Systems • 16. Scope of Project 15

D. Governance • 17. Board Authority • 18. Board Composition May 25, 2016 • 19. Conflict of Interest Policy Peak Performance Physicians, LLC 16

A. NEED 1. Needs Assessment Requirement: May 25, 2016 • Health center demonstrates and documents the Peak Performance Physicians, LLC needs of its target population, updating its service area, when appropriate. (Section 330(k)(2) and section 330(k)(3)(J) of the PHS Act) 17

A. Need – Cont’d 1. Needs Assessment – Cont’d • Health center performs periodic needs assessments. May 25, 2016 • Assessments document the needs of its target population in order to inform and improve its delivery of appropriate services. Peak Performance Physicians, LLC • A needs assessment typically includes, but is not limited to data on: • Population to Primary Care Physician FTE ratio. • Percent of population at or below 200% of poverty. • Percent of uninsured population. • Proximity to providers who accept Medicaid and/or uninsured patients. • Health indicators (e.g., diabetes, hypertension, low birthweight, 18 immunization rates).

B. SERVICES 2. Required and Additional Services Requirement: May 25, 2016 • Health center provides all required primary, preventive, enabling health services and additional health services as appropriate and Peak Performance Physicians, LLC necessary, either directly or through established written arrangements and referrals. (Section 330(a) of the PHS Act) NOTE: Health centers requesting funding to serve homeless individuals and their families must provide substance abuse services among their required services. (Section 330(h)(2) of the PHS Act) 19

B. Services – Cont’d Required and Additional Services – Cont’d • Ensures the health center is directly providing or has written May 25, 2016 arrangements and referrals in place to provide a comprehensive array of required and as necessary, additional primary and preventive services that meet the needs of the Peak Performance Physicians, LLC populations it serves. • All services in the health center’s scope of project must be reasonably accessible and available on a sliding fee scale to health center patients. • In scope referral arrangements must be formally documented in a written agreement (MOA, MOU, etc.) that at a minimum describes the manner by which the referral will be made and managed and the process for referring patients back to the 20 health center for appropriate follow ‐ up care.

B. Services – Cont’d 1. Staffing Requirement: May 25, 2016 • Health center maintains a core staff as necessary to carry out all required primary, preventive, enabling health services and Peak Performance Physicians, LLC additional health services as appropriate and necessary, either directly or through established arrangements and referrals. Staff must be appropriately licensed, credentialed and privileged. (Section 330(a)(1),(b)(1) ‐ (2),(k)(3)(C), and (k)(3)(I) of the PHS Act) 21

B. Services ‐‐ Cont’d Staffing Requirement – Cont’d • Staff composition and numbers must support the health May 25, 2016 center’s Clinical Performance Goals and ability to provide required and additional services. • All health center providers are appropriately licensed, credentialed and privileged to perform the activities and Peak Performance Physicians, LLC procedures detailed within the health center’s approved scope of project. • See BPHC credentialing and privileging policies for more information at http://bphc.hrsa.gov/archive/technicalassistance/resourcecenter/cli nicalservices/lipcredentialingchecklist.pdf • Staffing should be culturally and linguistically appropriate for the population being served and as noted in the health 22 center’s needs assessment.