Amy K. Fehn. I. Overview of Accountable Care Organizations and the Medicare Shared Savings Program

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Amy K. Fehn. I. Overview of Accountable Care Organizations and the Medicare Shared Savings Program"

Transcription

1 IMPLEMENTING COMPLIANCE PROGRAMS FOR ACCOUNTABLE CARE ORGANIZATIONS Amy K. Fehn I. Overview of Accountable Care Organizations and the Medicare Shared Savings Program The Medicare Shared Savings Program ( MSSP ) was established by Section 3022 of the Affordable Care Act. The MSSP allows certain Medicare providers and suppliers to join together as an Accountable Care Organization ( ACO ) to be accountable for the care of a population of Medicare beneficiaries. An ACO will enter into Participation Agreements with groups of providers/suppliers who are identified by a separate tax identification number ( Participants ). If an ACO meets all program requirements, including certain quality standards, the ACO will receive a percentage of any savings in Medicare program expenditures during the performance year at issue, when compared to benchmark expenditures. Although the term ACO is not specific to the MSSP, the MSSP regulations include very specific requirements for ACOs participating in the MSSP. One such requirement is the development and maintenance of a compliance program that meets certain criteria as set forth in the MSSP: ACO Final Rule issued on November 2, 2011 ( Final Rule ) Fed. Reg (November 2, 2011). 1

2 II. MSSP Compliance Program Requirements While the ACO s compliance program does not have to be submitted with the ACO s application, it must be made available to the Centers of Medicare and Medicaid Services ( CMS ) upon request and must meet certain requirements. 2 Specifically, 42 CFR contains a requirement that, in order to be eligible for the MSSP program, an ACO must have a compliance program that includes at least the following elements (which are discussed individually in more detail below): A designated compliance officer who is not legal counsel and who reports directly to the ACO s governing body. Mechanisms for identifying and addressing compliance problems related to the ACO s operations and performance. 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 the ACO to anonymously report suspected problems related to the ACO to the compliance officer. Compliance training for the ACO, the ACO participants, and the ACO providers/suppliers. A requirement for the ACO to report probable violations of law to an appropriate law enforcement agency. 2 Note that the regulations at 42 CFR suggest that ACO s must submit a copy of their compliance program with their application for the MSSP, the 2013 Application Toolkit does not indicate that the compliance program must be submitted with the application: Payment/sharedsavingsprogram/Downloads/MSSP-Reference-Table-.pdf 2

3 In compliance with and updated periodically to reflect changes in the law and regulations. 3 In the Final Rule, CMS also stated that, when developing compliance programs, ACOs should reference the compliance guidance on the Office of Inspector General s ( OIG ) website, which the OIG has issued through the years for various industry segments. 4 Thus, where the Final Rule does not provide specific guidance, it is helpful to look to this guidance regarding CMS expectations. A. A designated compliance officer who is not legal counsel and who reports directly to the ACO s governing body. Consistent with previous compliance guidance issued by the OIG, CMS is requiring ACOs participating in the MSSP to have a designated compliance officer. CMS further specified that the compliance officer be separate from legal counsel and report directly to the governing board. CMS clarified in commentary to the Final Rule that the compliance officer can be trained as an attorney, so long as the compliance officer does not act as legal counsel for the ACO. CMS stated that the purpose of this requirement is to ensure independent and objective legal reviews and financial analyses of the organization s compliance efforts and activities by the compliance officer. 5 If an ACO is an existing entity, it may use the entity s current compliance officer, but only if the compliance officer meets the requirements set forth above (i.e., is not legal counsel and reports directly to the ACO s governing body). 6 Although the regulations are silent as to the necessity of a compliance committee, the OIG Supplemental Compliance Program Guidance for Hospitals issued in CFR Fed. Reg Fed. Reg Id. 3

4 suggests that, at least for hospitals, a Compliance Committee is integral to the establishment of an effective compliance program. 7 The OIG has also recommended the establishment of a compliance committee in its compliance guidance for other industries, including that issued for Managed + Choice Organizations. 8 B. Mechanisms for identifying and addressing compliance problems related to the ACO s operations and performance. The OIG, in its compliance guidance, has consistently promoted the use of internal periodic audits by individuals who are knowledgeable about health care regulatory requirements. 9 In determining how to conduct internal audits, it is helpful to consider the methods in which CMS plans to audit ACOs in order to determine compliance with the various MSSP requirements. For example, in the Final Rule, CMS stated that it may audit quality measures data by reviewing beneficiary records. 10 CMS has also stated that it may audit ACOs for accuracy of ICD-9 codes on which risk scores are based. 11 In addition, CMS stated plans to monitor for beneficiary risk avoidance by looking for patterns in changes in risk adjustment of the ACO s assigned population from one year to the next. 12 CMS has also indicated that it will monitor beneficiary surveys to determine whether ACOs are interfering with patient freedom of choice by improperly limiting or restricting referrals to providers within the ACO Fed. Reg Fed. Reg See e.g., OIG s Compliance Program Guidance for Medicare + Choice Organizations, 64 Fed. Reg Fed. Reg Fed. Reg Fed. Reg Fed. Reg

5 These potential areas of CMS audit are discussed in more detail below, as are other regulatory requirements that could post compliance risks for the ACO. C. 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 the ACO to anonymously report suspected problems related to the ACO to the compliance officer. CMS does not elaborate on the anonymous reporting requirement in the Final Rule. However, in past compliance guidance, the OIG has suggested the use of a hotline or drop box for the receipt of anonymous complaints. 14 D. Compliance training for the ACO, the ACO participants, and the ACO providers/suppliers. In the commentary to the Final Rule, some commenters requested that, to minimize the burden on ACOs, CMS require only training of the compliance officer. In response, CMS stated that the compliance training was necessary for all ACO participants and ACO providers/suppliers so that all associated providers/suppliers would understand their legal obligations and the ACO s legal obligations with respect to the ACO s operations, compliance risk areas and how to report compliance concerns. 15 E. A requirement for the ACO to report probable violations of law to an appropriate law enforcement agency. The Proposed Rule contained a duty to report suspected violations of law. In the Final Rule, commenters suggested that this requirement deviated from accepted compliance practices. Commenters specifically had concerns that the required reporting of suspected violations would not give the ACO an opportunity to resolve issues before reporting to law enforcement. 14 OIG Compliance Guidance for Hospitals and Medicare + Choice Organizations both discuss the use of hotlines, while the Compliance Guidance for Individual and Small Group Physician Practices suggests the use of a drop box Fed. Reg

6 In the Final Rule, CMS changed the duty to require reporting of probable violations of law, stating: [w]e believe ACOs should have a compliance program that allows for the prompt and thorough investigation of possible misconduct by ACO participants, ACO providers/suppliers, other individuals or entities performing functions or services related to ACO activities, corporate officers, managers, employees, and independent contractors, as well as, early detection and reporting of violations, thus minimizing the loss to the Federal government from false or improper claims and thereby reducing the ACO and ACO participants and its ACO providers/suppliers to applicable civil damages and penalties, criminal sanctions, or administrative remedies, such as program exclusion, as applicable. As such, ACOs should consider implementing a system for identifying and addressing possible violations when designing their compliance plan. We are modifying the final rule to provide that probable violations should be reported to law enforcement. 16 Thus, ACOs will likely want to craft compliance policies in a manner that requires participants and employees to report suspected violations internally, giving the ACO the opportunity to fully investigate whether a probable violation exists. F. In compliance with and updated periodically to reflect changes in the law and regulations. Consistent with previous OIG guidance, ACOs are required to update compliance programs periodically as necessary to reflect changes in the law and regulations. This is important because CMS noted throughout the Final Rule commentary that it will monitor and update the requirements as needed. 17 Thus, it is likely that requirements will be removed, revised or eliminated as the MSSP is further evaluated by CMS Fed. Reg CFR gives CMS the ability to update the program requirements during the term of the agreement. 6

7 In commentary to the Final Rule, CMS also indicated that one purpose of this provision was to require compliance with the new mandatory compliance provisions of the Accountable Care Act. 18 III. Specific Risk Areas and Associated Penalties The OIG frequently advises providers, when implementing compliance programs, to focus on risk areas specific to their provider type. Some of the areas that could potentially pose risk of noncompliance with the MSSP regulations, or other regulations related to ACO participation in the MSSP, include: A. Accuracy of Data Submitted Pursuant to 42 CFR , at the time data is submitted by an ACO, an individual with the legal authority to bind the ACO must certify the accuracy, completeness and truthfulness of the data and information to the best of his or her knowledge, information and belief. In addition, an individual with the legal authority to bind the ACO must submit an annual certification that, to the best of his or her knowledge, information and belief, the ACO and its Participants, providers and suppliers are in compliance with program requirements. The individual must also certify the accuracy of all data and information generated or submitted by the ACO, its Participants, its associated providers/suppliers and any individuals or entities performing functions or services related to ACO activities Note that pursuant to Section 6101 of the Affordable Care Act, the Secretary of Health and Human Services (HHS) is required to develop mandatory compliance program requirements for certain other health care providers or suppliers, as determined by HHS. Section 6401 requires mandatory compliance programs for Skilled Nursing Facilities (SNFs) but a final rule regarding specific requirements has yet to be issued CFR

8 The commentary to the Final Rule contains a reminder that knowingly submitting a false certification could trigger liability under the False Claims Act, as well as termination from the MSSP program. 20 Thus, it is important that ACO employees and Participants understand the importance of accurate submissions. B. Beneficiary Inducements The Final Rule also prohibits ACOs and its Participants from providing gifts or other remuneration to beneficiaries as inducements for receiving items or services from, or remaining in, an ACO, or with ACO providers/suppliers in a particular ACO. The Final Rule does provide exceptions for certain in-kind items or services provided to beneficiaries if they are reasonably connected to the beneficiaries care, are preventive care items or services, or advance a clinical goal for the beneficiary (such as adherence to a drug or treatment regime, a follow-up care plan or chronic disease management). 21 In order to use this exception, an ACO must be in good standing with regard to its participation in the MSSP program, and the goods or services must be reasonably connected to the medical care of the beneficiary. 22 The provision of such goods and services also requires waiver of the beneficiary inducement civil monetary penalties ( CMP ), as discussed in more detail below. In commentary to the Final Rule, CMS provided examples of the types of beneficiary inducements that are permissible, such as giving blood pressure monitors to patients with hypertension in order to encourage regular blood pressure monitoring. CMS also provided examples of the types of beneficiary inducements that are Fed. Reg CFR (a) Fed. Reg

9 impermissible, such as offering beneficiaries money or other gifs such as baseball tickets or gift cards to retail stores. 23 C. Screening of ACO Applicants The Final Rule states that all ACOs, including Participants, providers and suppliers will be reviewed initially and periodically to screen for any exclusions from the Medicare program or other sanctions as well as affiliations with individuals or entities that have a history of program integrity issues. 24 If CMS discovers excluded providers who are participating in or affiliated with the ACO, the MSSP application could be denied, or additional program safeguards could be put into place. 25 Therefore, it is important that ACOs have an effective screening process in place. D. Prohibition on Certain Required Referrals and Cost Shifting ACOs are prohibited from requiring that Participants refer within the ACO for non-aco patients. 26 The purpose of this requirement is to address concerns that, with the preliminary prospective beneficiary assignment, ACOs might incent participants to over utilize services related to beneficiaries who are not assigned to that ACO. 27 The Final Rule also prohibits ACOs from requiring that beneficiaries be referred within the ACO. 28 The purpose of this requirement is to maintain beneficiary freedom of choice Fed. Reg CFR (b) 25 Id CFR (c)(1) Fed. Reg CFR (c)(2) Fed. Reg

10 E. Updating Application Information ACOs are also required to update their application for any changes in National Provider Identifiers or Tax Identification Numbers submitted within 30 days of a change. 30 It may be helpful to include a reminder of this requirement in compliance training. F. Marketing ACOs must submit all marketing materials to CMS for approval and cannot use the information until five days after the submission to CMS. 31 ACOs must also certify that the marketing materials comply with the following requirements: Marketing materials must use template language developed by CMS, if available. The marketing materials may be targeted toward beneficiaries of certain races or with certain conditions, but must not be used in a discriminatory manner or for a discriminatory purpose. Marketing communications cannot violate the beneficiary inducement provisions discussed above and must not be materially inaccurate or misleading 32 G. Beneficiary Notification ACO participants must notify beneficiaries at the point of care that their providers/suppliers are participating in the MSSP. 33 Notification must be made by CFR (d) CFR CFR (c) CFR (a). 10

11 posting signs and via a standardized written notice. The ACO may also inform beneficiaries that they have been preliminarily assigned to the ACO. 34 It is also important to note that CMS views these notification documents as marketing. Thus, all such documents must meet all marketing requirements discussed above (including the submission of the materials to CMS). 35 H. Avoidance of At-Risk Beneficiaries CMS is required by statute to monitor ACOs for behavior that would indicate that the ACO is avoiding at risk beneficiaries. 36 While the Affordable Care Act does not define the term at risk beneficiary, CMS defines it in the Final Rule: At-risk beneficiary means, but is not limited to, a beneficiary who (1) Has a high risk score on the CMS HCC risk adjustment model; (2) Is considered high cost due to having two or more hospitalizations or emergency room visits each year; (3) Is dually eligible for Medicare and Medicaid; (4) Has a high utilization pattern; (5) Has one or more chronic conditions; (6) Has had a recent diagnosis that is expected to result in increased cost; (7) Is entitled to Medicaid because of disability; or (8) Is diagnosed with a mental health or substance abuse disorder. 37 If CMS determines that an ACO has been avoiding at risk beneficiaries, the ACO will be subject to sanctions, including possible termination from the MSSP. 38 Thus, it is important that participating providers understand the prohibition on avoiding at-risk beneficiaries. As discussed above, CMS will be reviewing changes in beneficiary assignment to audit for possible avoidance behaviors CFR (b) CFR (c). 36 Affordable Care Act Section CFR Affordable Care Act Section

12 This is an area where the compliance officer could take a proactive approach with self-audits. Other ways to self-monitor for these avoidance types of behaviors could include beneficiary interviews or requirements that a provider report to the ACO when he or she terminates a physician-patient relationship. I. Data Use Agreement and HIPAA Compliance Subject to beneficiaries rights to opt-out of data sharing, CMS may share beneficiary data with ACOs for activities such as quality assurance/quality improvement and population based activities. However, in order to receive such data, ACOs must sign a Data Use Agreement and must require all Participants (and associated providers/suppliers) to comply with the terms of the Data Use Agreement. 39 Failure to comply with the Data Use Agreement provisions will cause the ACO to be ineligible to receive beneficiary data and could subject the ACO to termination and other sanctions/penalties. 40 ACOs will also likely be considered a business associate of the Participants to the extent that they require protected health information from the Participants. 41 ACOs could, therefore, be subject to HIPAA fines and penalties for impermissible disclosures of protected health information. J. Anti-Kickback and Stark Concurrent with the Final Rule, CMS, jointly with the OIG, also issued an Interim Final Rule with Comment Period (the IFC ) establishing waivers of the application of the Physician Self-Referral Law ( Stark ), the federal anti-kickback statute (the AKS ), CFR CFR (a)(2) Fed. Reg

13 and certain CMP law provisions to certain ACO arrangements as necessary to implement the MSSP. 42 It is important for ACOs and their Participants to understand, however, that these waivers are limited and are not a wholesale waiver of these laws and regulations. The available waivers protect the following five arrangements/activities: ACO Pre-participation Waiver. This waiver protects startup arrangements that pre-date an ACO s participation agreement, so long as the parties forming the ACO are working with a good faith intent to develop an ACO that will participate in the MSSP during a target year. The parties to the arrangement may include the ACO and at least one entity that is eligible to become a participant, but may not include drug and device manufacturers, distributors, durable medical equipment ( DME ) suppliers, or home health suppliers. The parties developing the ACO must be taking diligent steps to develop an ACO that would be eligible for a participation agreement that would become effective during the target year, including developing a governing body. The governing body must make a determination that the arrangement is reasonably related to the purposes of the MSSP. The documented arrangement and authorization must be retained for a period of ten years. If the ACO does not submit an application for the MSSP, it must send an explanation to CMS. If all conditions are met, a pre-participation waiver would begin one year preceding the due date of a target year application and would end on the start date of an accepted participation agreement. Arrangements that were in place on the date of denial will continue to be protected by the waiver for six more months. An ACO that fails to meet the target application date may request a one-time extension Fed. Reg Fed. Reg

14 ACO Participation Waiver. This waiver is available for ACOs that have entered into a participation agreement with CMS for the MSSP and remain in good standing. The ACO s governing body must make a good faith determination that the arrangement is reasonably related to the purposes of the MSSP. The arrangement and the governing body s authorization must be documented contemporaneously and retained for 10 years. The waiver begins on the start date of the participation agreement and will end 6 months after termination or expiration of the participation agreement. However, if CMS terminates the participation agreement, the waiver period will end immediately upon termination. 44 ACO Shared Savings Distribution Waiver. This waiver is available for ACOs that are participating in the MSSP and distribute shared savings during the year in which the shared savings were earned by the ACO. The waiver also protects shared savings that are used for activities that are reasonably related to the purposes of the MSSP. However, the distributions cannot knowingly be made from a hospital to a physician to induce the physician to reduce or limit medically necessary items or services to patients under the direct care of the physician. 45 Compliance with the Physician Self-Referral Waiver. This waiver protects arrangements, as to applicability of the AKS or the gainsharing CMP, between ACOs participating in the MSSP and physicians provided that the arrangement meets a Stark exception. 46 Waiver for Patient Inducements. As discussed above with regard to beneficiary inducements, the AKS and beneficiary inducement CMP will be waived Fed. Reg Id. 46 Id. 14

15 where participating ACOs provide patients with healthcare-related incentives that meet certain criteria. The waiver will begin on the start date of the ACO s participation agreement and will end at expiration or termination. However, a beneficiary may keep any items received during the term of the participation agreement and receive the remainder of any service initiated prior to the termination or expiration of the participation agreement. 47 K. Anti-Trust Concurrent with the publication of the Final Rule, the Federal Trade Commission ( FTC ) and Department of Justice ( DOJ ) issued a final Antitrust Enforcement Policy with regard to ACOs participating in the MSSP. 48 Absent extraordinary circumstances, an ACO will fall within an antitrust enforcement safety zone if independent ACO participants that provide the same service have a share of 30 percent or less of the common service in each participant s Primary Service Area ( PSA ). Because of the qualification related to extraordinary circumstances, and because some ACOs will not fall within the safety zone, all compliance programs should provide guidance to ACO participants regarding conduct to avoid. For example all ACOs should avoid improper exchanges of prices or other competitively sensitive information among competing participants and should implement appropriate firewalls or other safeguards to protect against collusion among competing participants. 49 ACO Participant conduct that the FTC and DOJ would consider concerning when associated with an ACO with high PSA shares or other indicia of market power include: Fed. Reg Fed. Reg Fed. Reg

16 Preventing or discouraging private payors from directing or incentivizing patients to choose certain providers; Exclusive contracting with ACO physicians, hospitals, ASCs or other providers which would prevent or discourage those providers from contracting with private payers outside of the ACO; and Restricting a private payor from making costs, quality, efficiency and performance information available to aid enrollees in evaluating and selecting health plan providers, if that information is similar to the information used for the MSSP 50 L. Reporting Changes ACOs must notify CMS within thirty days of an addition or removal of an ACO Participant or any significant change to the initially approved structure. A significant change is defined as any change that would cause an ACO to not be able to meet the eligibility or program requirements of the MSSP. 51 M. Record Retention ACOs are required to retain records related to the MSSP program for a period of ten years unless CMS instructs the ACO to retain the records longer. Also, if there is a dispute, such as a termination or allegation of fraud, the ACO should retain the medical records for an additional six years from the date of any resulting final resolution. 52 IV. Conclusion Compliance plans are not only required by the Final Rule, but can also help ACOs to meet the many complicated program requirements. For effectiveness, it is essential Fed. Reg CFR CFR

17 that meaningful training take place and that such training reach all of the Participant s associated physicians. Self-monitoring, regular review, and update of the policies and procedures are other factors that will promote a culture of compliance within the ACO. 17

Cornerstone Health Care, P.A.

Cornerstone Health Care, P.A. Cornerstone Health Care, P.A. Medicare Shared Savings Program ACO Compliance NAACOS July 2013 Agenda 1. Background 2. Compliance Requirements & Purpose 3. Cornerstone s experience 4. Q&A 2 Cornerstone

More information

Fraud and Abuse Considerations for Accountable Care Organizations (ACOs)

Fraud and Abuse Considerations for Accountable Care Organizations (ACOs) Fraud and Abuse Considerations for Accountable Care Organizations (ACOs) By: Chris Rossman, Foley & Lardner LLP, Detroit, Michigan 1. The Centers for Medicare and Medicaid Services ( CMS ) and the Office

More information

ACOs: Fraud & Abuse Waivers and Analysis

ACOs: Fraud & Abuse Waivers and Analysis ACOs: Fraud & Abuse Waivers and Analysis Robert G. Homchick and Sarah Fallows Davis Wright Tremaine, LLP I. Introduction The Patient Protection and Affordable Care Act of 2010 (ACA) fosters the development

More information

Accountable Care Organizations

Accountable Care Organizations Building a Healthy ACO Compliance Program HCCA 2014 Compliance Institute Mary C. Malone, Esq. Hancock, Daniel, Johnson & Nagle, P.C. Disclaimer: The content of this presentation does not constitute legal

More information

Fraud & Abuse Waivers Under the Medicare Shared Savings Program

Fraud & Abuse Waivers Under the Medicare Shared Savings Program Fraud & Abuse Waivers Under the Medicare Shared Savings Program Robert G. Homchick Davis Wright Tremaine, LLP I. Introduction The Patient Protection and Affordable Care Act of 2010 (ACA) fosters the development

More information

Accountable Care Organization. Medicare Shared Savings Program. Compliance Plan

Accountable Care Organization. Medicare Shared Savings Program. Compliance Plan Accountable Care Organization Participating In The Medicare Shared Savings Program Compliance Plan 2014 Corporate Location: 3190 Fairview Park Drive Falls Church, VA 22042 ARTICLE I INTRODUCTION This Compliance

More information

Accountable Care Organizations

Accountable Care Organizations Building a Healthy ACO Compliance Program: Good Help ACO s Experience in Building Healthy Communities While Leveraging Existing Resources to Establish a Healthy and Effective ACO Compliance Program. Mary

More information

Accountable Care Organizations Multiple Comment Periods

Accountable Care Organizations Multiple Comment Periods Accountable Care Organizations Multiple Comment Periods Proposed Waivers CMS and OIG CMS and HHS Office of Inspector General (OIG) jointly issued a notice with comment period outlining proposals for waivers

More information

In early April, the Center for Medicare and Medicaid Services (CMS) issued

In early April, the Center for Medicare and Medicaid Services (CMS) issued April 26, 2011 If you have any questions regarding the matters discussed in this memorandum, please contact the following attorneys or call your regular Skadden contact. John T. Bentivoglio 202.371.7560

More information

CMS Releases Proposed Rule Governing Accountable Care Organizations

CMS Releases Proposed Rule Governing Accountable Care Organizations CMS Releases Proposed Rule Governing Accountable Care Organizations Health Care Organizations Face Complex Strategic Decisions Authors: Robert D. Belfort Paul M. Campbell Susan R. Ingargiola Stephanie

More information

SAINT FRANCIS HEALTHCARE PARTNERS ACO, INC. CORPORATE COMPLIANCE PLAN. Adopted by Resolution of the Board of Directors on June 24, 2014

SAINT FRANCIS HEALTHCARE PARTNERS ACO, INC. CORPORATE COMPLIANCE PLAN. Adopted by Resolution of the Board of Directors on June 24, 2014 SAINT FRANCIS HEALTHCARE PARTNERS ACO, INC. CORPORATE COMPLIANCE PLAN Adopted by Resolution of the Board of Directors on June 24, 2014 TABLE OF CONTENTS PAGE CORPORATE COMPLIANCE PLAN... 1 MISSION STATEMENT

More information

ACO Fraud and Abuse Provisions

ACO Fraud and Abuse Provisions MAY 6 2011 ACO Fraud and Abuse Provisions BY BRIAN P. DUNPHY AND ELLYN L. STERNFIELD On March 31, 2011, a little over a year after the Patient Protection and Affordable Care Act (PPACA), as amended by

More information

Medicare ACO Road Map

Medicare ACO Road Map PYALeadership Briefing Medicare ACO Road Map January, 2013 Medicare ACO Road Map The Centers for Medicare & Medicaid Services ( CMS ) has announced 106 new accountable care organizations ( ACOs ) have

More information

A Closer Look at the Final ACO Rule

A Closer Look at the Final ACO Rule A Closer Look at the Final ACO Rule October 2011 For more information, please contact: On October 20th, the federal government released a final rule and other companion releases relating to Accountable

More information

Medicare (Pioneer) Accountable Care Organization. Annual Compliance Training

Medicare (Pioneer) Accountable Care Organization. Annual Compliance Training Medicare (Pioneer) Accountable Care Organization Annual Compliance Training Overview While health care professionals have long been concerned about patient safety, increased public awareness and transparency

More information

Accountable Care Organizations and Provider Integration Under Health Care Reform. Sarah Swank 202.326.5003 seswank@ober.com

Accountable Care Organizations and Provider Integration Under Health Care Reform. Sarah Swank 202.326.5003 seswank@ober.com Accountable Care Organizations and Provider Integration Under Health Care Reform Sarah Swank 202.326.5003 seswank@ober.com February 26, 2014 Overview Affordable Care Act and ACOs Trends in Integration

More information

Guidance Released on Accountable Care Organizations Participating in the Medicare Shared Savings Program

Guidance Released on Accountable Care Organizations Participating in the Medicare Shared Savings Program M A Y 2 0 1 1 Guidance Released on Accountable Care Organizations Participating in the Medicare Shared Savings Program On March 31, 2011, the Centers for Medicare & Medicaid Services (CMS), the Department

More information

Additional Information About Accountable Care Organizations

Additional Information About Accountable Care Organizations Additional Information About Accountable Care Organizations For more information, please contact: April 2011 On March 31st, the federal government outlined proposed actions relating to Accountable Care

More information

Medicare Advantage and Part D Fraud, Waste, and Abuse Training. October 2010

Medicare Advantage and Part D Fraud, Waste, and Abuse Training. October 2010 Medicare Advantage and Part D Fraud, Waste, and Abuse Training October 2010 Introduction 2008: United States spent $2.3 trillion on health care. Federal fiscal year 2010: Medicare expected to cover an

More information

Department of Health and Human Services. No. 209 October 29, 2015. Part III

Department of Health and Human Services. No. 209 October 29, 2015. Part III Vol. 80 Thursday, No. 209 October 29, 2015 Part III Department of Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Chapter IV Office of Inspector General 42 CFR Chapter V Medicare

More information

Health Connect Partners, LLC

Health Connect Partners, LLC Medicare Shared Savings Program Self-Guided ACO Compliance Training January 2015 1 This year s ACO compliance training is self-guided. Simply read through these questions and answers, and contact the compliance

More information

Fraud, Waste, and Abuse

Fraud, Waste, and Abuse These training materials are divided into three topics to meet the responsibilities stated on the previous pages: Fraud, Waste, Compliance Program Standards of Conduct Although the information contained

More information

DETAILED SUMMARY--MEDCIARE SHARED SAVINGS/ACCOUNTABLE CARE ORGANIZATION (ACO) PROGRAM

DETAILED SUMMARY--MEDCIARE SHARED SAVINGS/ACCOUNTABLE CARE ORGANIZATION (ACO) PROGRAM 1 DETAILED SUMMARY--MEDCIARE SHARED SAVINGS/ACCOUNTABLE CARE ORGANIZATION (ACO) PROGRAM Definition of ACO General Concept An ACO refers to a group of physician and other healthcare providers and suppliers

More information

Compliance Training for Medicare Programs Version 1.0 2/22/2013

Compliance Training for Medicare Programs Version 1.0 2/22/2013 Compliance Training for Medicare Programs Version 1.0 2/22/2013 Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association. 1 The Compliance Program Setting standards

More information

USC Office of Compliance

USC Office of Compliance PURPOSE This policy complies with requirements under the Deficit Reduction Act of 2005 and other federal and state fraud and abuse laws. It provides guidance on activities that could result in incidents

More information

PROPOSED MEDICARE SHARED SAVINGS (ACO) PROGRAM RULES

PROPOSED MEDICARE SHARED SAVINGS (ACO) PROGRAM RULES PROPOSED MEDICARE SHARED SAVINGS (ACO) PROGRAM RULES The Centers for Medicare and Medicaid Services (CMS) and other affected agencies released their notice of proposed rulemaking/request for comment for

More information

II. SHARED SAVINGS PROGRAM AND COST-REDUCTION INCENTIVES

II. SHARED SAVINGS PROGRAM AND COST-REDUCTION INCENTIVES E-ALERT Health Care April 15, 2011 ACCOUNTABLE CARE ORGANIZATION BASICS The Affordable Care Act establishes the Medicare Shared Savings Program ( Program ), which provides for the development of accountable

More information

Accountable Care Organizations: The Final Rule

Accountable Care Organizations: The Final Rule Accountable Care Organizations: The Final Rule October 27, 2011 2011 Akin Gump Strauss Hauer & Feld LLP 10.27.11 101799002 v4 Overview Background Final Rule Highlights Structure and Formation of ACOs Quality

More information

Physician Integration Models: ACOs as the Latest and Greatest? David T. Lewis david.lewis@lpnt.net LifePoint Hospitals, Inc.

Physician Integration Models: ACOs as the Latest and Greatest? David T. Lewis david.lewis@lpnt.net LifePoint Hospitals, Inc. Physician Integration Models: ACOs as the Latest and Greatest? David T. Lewis david.lewis@lpnt.net LifePoint Hospitals, Inc. Brentwood, TN Kim Harvey Looney kim.looney@wallerlaw.com Waller Lansden Dortch

More information

See page 16. Thomas A. Vallas

See page 16. Thomas A. Vallas Compliance TODAY July 2014 a publication of the health care compliance association www.hcca-info.org What s the key to successfully merging two large hospital systems? an interview with Michael R. Holper

More information

CMS-1345-NC2: Waiver Designs in Connection With the Medicare Shared Savings Program and the Innovation Center

CMS-1345-NC2: Waiver Designs in Connection With the Medicare Shared Savings Program and the Innovation Center Submitted Electronically Donald Berwick, M.D., M.P.P. Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Room 445-G, Hubert H. Humphrey Building 200 Independence

More information

Client Advisory. CMS Issues Final ACO Regulations EXECUTIVE SUMMARY. Health Care. Eligibility. November 10, 2011

Client Advisory. CMS Issues Final ACO Regulations EXECUTIVE SUMMARY. Health Care. Eligibility. November 10, 2011 Client Advisory Health Care November 10, 2011 CMS Issues Final ACO Regulations After receiving more than 1,300 public comments on its Proposed Rule for Accountable Care Organizations (ACOs) under the Medicare

More information

To: All Vendors, Agents and Contractors of Hutchinson Regional Medical Center

To: All Vendors, Agents and Contractors of Hutchinson Regional Medical Center To: All Vendors, Agents and Contractors of Hutchinson Regional Medical Center From: Corporate Compliance Department Re: Deficit Reduction Act of 2005 Dear Vendor/Agent/Contractor: Under the Deficit Reduction

More information

BAPTIST PHYSICIAN ALLIANCE ACO AGREEMENT for MEDICARE SHARED SAVINGS PROGRAM PARTICIPATION

BAPTIST PHYSICIAN ALLIANCE ACO AGREEMENT for MEDICARE SHARED SAVINGS PROGRAM PARTICIPATION BAPTIST PHYSICIAN ALLIANCE ACO AGREEMENT for MEDICARE SHARED SAVINGS PROGRAM PARTICIPATION ( Physician Practice ) hereby agrees to become a Participant in the Medicare Shared Savings Program ( MSSP ) pursuant

More information

AppleCare. 2013 General Compliance Training

AppleCare. 2013 General Compliance Training AppleCare 2013 General Compliance Training Goals After completing this course, you will understand: The Principles of Ethics and Integrity and the Compliance Plan How to report a suspected or detected

More information

NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS. Briefing Paper on the Proposed Medicare Shared Savings Program

NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS. Briefing Paper on the Proposed Medicare Shared Savings Program NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS Briefing Paper on the Proposed Medicare Shared Savings Program The Centers for Medicare and Medicaid Services (CMS) recently issued a proposed rule to implement

More information

FRAUD AND ABUSE (SECTION-BY-SECTION ANALYSIS)

FRAUD AND ABUSE (SECTION-BY-SECTION ANALYSIS) FRAUD AND ABUSE (SECTION-BY-SECTION ANALYSIS) (Information compiled from the Democratic Policy Committee (DPC) Report on The Patient Protection and Affordable Care Act and the Health Care and Education

More information

Developed by the Centers for Medicare & Medicaid Services

Developed by the Centers for Medicare & Medicaid Services Developed by the Centers for Medicare & Medicaid Services Every year millions of dollars are improperly spent because of fraud, waste, and abuse. It affects everyone. Including YOU. This training will

More information

Understanding Health Reform s

Understanding Health Reform s Compliance 101: Understanding Health Reform s New Compliance Requirements Uri Bilek Feldesman Tucker Leifer Fidell LLP Does your organization have a designated Compliance Officer? a. Yes b. No c. Don't

More information

COMPLIANCE AND FRAUD, WASTE AND ABUSE

COMPLIANCE AND FRAUD, WASTE AND ABUSE Neighborhood requires compliance with all laws applicable to the organization s business, including insistence on compliance with all applicable federal and state laws dealing with false claims and false

More information

Entities eligible for ACO participation

Entities eligible for ACO participation On Oct. 20, 2011, the Centers for Medicare & Medicaid Services (CMS) finalized new rules under the Medicare Shared Savings Program (MSSP) to help doctors, hospitals, and other health care providers better

More information

The Anti-Kickback Statute: A continuing compliance challenge. Suzanne Dallas Castaldo

The Anti-Kickback Statute: A continuing compliance challenge. Suzanne Dallas Castaldo Compliance TODAY February 2014 a publication of the health care compliance association www.hcca-info.org Congratulations, Brian! an interview with Brian Patterson the 6,000 th person actively certified

More information

Federal Fraud and Abuse Laws

Federal Fraud and Abuse Laws Federal Fraud and Abuse Laws Remaining in Compliance while Attesting to Meaningful Use 1 Overview This presentation provides an overview of key Federal laws aimed at preventing healthcare fraud and abuse

More information

CORPORATE COMPLIANCE: BILLING & CODING COMPLIANCE

CORPORATE COMPLIANCE: BILLING & CODING COMPLIANCE SUBJECT: CORPORATE COMPLIANCE: BILLING & CODING COMPLIANCE MISSION: Quality, honesty and integrity, in everything we do, are important values to all of us who are associated with ENTITY NAME ( ENTITY NAME

More information

PHI Air Medical, L.L.C. Compliance Plan

PHI Air Medical, L.L.C. Compliance Plan Page No. 1 of 13 Introduction: The PHI Air Medical, L.L.C. is to be used by employees, contractors and vendors to get a high level understanding of the key regulatory requirements relating to our participation

More information

NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS. Briefing Paper on the Proposed Medicare Shared Savings Program

NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS. Briefing Paper on the Proposed Medicare Shared Savings Program NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS Briefing Paper on the Proposed Medicare Shared Savings Program The Centers for Medicare and Medicaid Services (CMS) recently issued a proposed rule to implement

More information

Compliance and Program Integrity Melanie Bicigo, CHC, CEBS mlbicigo@uphp.com 906-225-7749

Compliance and Program Integrity Melanie Bicigo, CHC, CEBS mlbicigo@uphp.com 906-225-7749 Compliance and Program Integrity Melanie Bicigo, CHC, CEBS mlbicigo@uphp.com 906-225-7749 Define compliance and compliance program requirements Communicate Upper Peninsula Health Plan (UPHP) compliance

More information

Summary of Medicare Shared Savings Program Final Rule on Accountable Care Organizations

Summary of Medicare Shared Savings Program Final Rule on Accountable Care Organizations Summary of Medicare Shared Savings Program Final Rule on Accountable Care Organizations On November 2, 2011, the Centers for Medicare and Medicaid Services ( CMS ) published a Final Rule implementing the

More information

MEDICAID AND MEDICARE (PARTS C&D) FRAUD, WASTE AND ABUSE TRAINING

MEDICAID AND MEDICARE (PARTS C&D) FRAUD, WASTE AND ABUSE TRAINING MEDICAID AND MEDICARE (PARTS C&D) FRAUD, WASTE AND ABUSE TRAINING Why Do I Need Training/Where Do I Fit in? Why Do I Need Training? Every year millions of dollars are improperly spent because of fraud,

More information

KATHLEEN L. DEBRUHL & ASSOCIATES, L.L.C. 614 TCHOUPITOULAS STREET NEW ORLEANS, LOUISIANA 70130 504.522.4054 (OFFICE) 504.522.9049 (FAX) WWW.MD-LAW.

KATHLEEN L. DEBRUHL & ASSOCIATES, L.L.C. 614 TCHOUPITOULAS STREET NEW ORLEANS, LOUISIANA 70130 504.522.4054 (OFFICE) 504.522.9049 (FAX) WWW.MD-LAW. CMS RELEASES PROPOSED ACCOUNTABLE CARE ORGANIZATION REGULATIONS By: Kathleen L. DeBruhl, Esq. and Lindsey E. Surratt, Esq. On March 31, 2011, the Centers for Medicare and Medicaid Services ( CMS ) issued

More information

Discovering a Potential Overpayment: An Law, and Medicare Reimbursement Considerations

Discovering a Potential Overpayment: An Law, and Medicare Reimbursement Considerations Discovering a Potential Overpayment: An Overview of the False Claims Act, Stark Law, and Medicare Reimbursement Considerations, Stockholder, Reid & Riege, P.C., Stockholder, Reid & Riege, P.C. Outline

More information

Prepared by: The Office of Corporate Compliance & HIPAA Administration

Prepared by: The Office of Corporate Compliance & HIPAA Administration Gwinnett Health System s Annual Education 2014 Corporate Compliance: Our Commitment to Excellence Prepared by: The Office of Corporate Compliance & HIPAA Administration Objectives After completing this

More information

CORPORATE INTEGRITY AGREEMENT I. PREAMBLE

CORPORATE INTEGRITY AGREEMENT I. PREAMBLE CORPORATE INTEGRITY AGREEMENT BETWEEN THE OFFICE OF INSPECTOR GENERAL OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES AND MAXIM HEALTHCARE SERVICES, INC. I. PREAMBLE Maxim Healthcare Services, Inc. (Maxim)

More information

THE MONTEFIORE ACO CODE OF CONDUCT

THE MONTEFIORE ACO CODE OF CONDUCT THE MONTEFIORE ACO CODE OF CONDUCT Montefiore ACO Compliance Program Our Commitment to Compliance As a central part of its Compliance Program, the Bronx Accountable Healthcare Network IPA, Inc., d/b/a

More information

POLICY AND STANDARDS. False Claims Laws and Whistleblower Protections

POLICY AND STANDARDS. False Claims Laws and Whistleblower Protections POLICY AND STANDARDS Corporate Policy Applicability: Magellan BH (M) NIA (N) ICORE (I) Magellan Medicaid Administration (A) Corporate Policy: Policy Number: Policy Name: Date of Inception: January 1, 2007

More information

Standards of. Conduct. Important Phone Number for Reporting Violations

Standards of. Conduct. Important Phone Number for Reporting Violations Standards of Conduct It is the policy of Security Health Plan that all its business be conducted honestly, ethically, and with integrity. Security Health Plan s relationships with members, hospitals, clinics,

More information

Statement of the Association of American Medical Colleges on Legal Issues Related to Accountable Care Organizations and Healthcare Innovation Zones

Statement of the Association of American Medical Colleges on Legal Issues Related to Accountable Care Organizations and Healthcare Innovation Zones Statement of the Association of American Medical Colleges on Legal Issues Related to Accountable Care Organizations and Healthcare Innovation Zones Public Workshop hosted by the FTC, CMS, HHS OIG October

More information

Mental Health Resources, Inc. Mental Health Resources, Inc. Corporate Compliance Plan Corporate Compliance Plan

Mental Health Resources, Inc. Mental Health Resources, Inc. Corporate Compliance Plan Corporate Compliance Plan Mental Health Resources, Inc. Mental Health Resources, Inc. Corporate Compliance Plan Corporate Compliance Plan Adopted: January 2, 2007 Revised by Board of Directors on September 4, 2007 Revised and Amended

More information

A Roadmap for New Physicians. Avoiding Medicare and Medicaid Fraud and Abuse

A Roadmap for New Physicians. Avoiding Medicare and Medicaid Fraud and Abuse A Roadmap for New Physicians Avoiding Medicare and Medicaid Fraud and Abuse Introduction This tutorial is intended to assist new physicians in understanding how to comply with Federal laws that combat

More information

Look Before You Leap: Legal and Practical Obstacles with ACOs

Look Before You Leap: Legal and Practical Obstacles with ACOs Look Before You Leap: Legal and Practical Obstacles with ACOs Houston ACO Conference May 7, 2013 Edward Vishnevetsky, Esq. Coordinated Care and ACOs Coordinated Care Goal: ensure that healthcare providers

More information

HPC Healthcare, Inc. Administrative/Operational Policy and Procedure Manual

HPC Healthcare, Inc. Administrative/Operational Policy and Procedure Manual Operational and Procedure Manual 1 of 7 Subject: Corporate Compliance Plan Originating Department Quality & Compliance Effective Date 1/99 Administrative Approval Review/Revision Date(s) 6/00, 11/99, 2/02,

More information

SUBJECT: FRAUD AND ABUSE POLICY: CP 6018

SUBJECT: FRAUD AND ABUSE POLICY: CP 6018 SUBJECT: FRAUD AND ABUSE POLICY: Department of Origin: Compliance & Audit Responsible Position: Vice President of Compliance and Audit Date(s) of Review and Revision: 07/10; 04/11; 11/11; 02/12; 6/12;

More information

2012-2013 MEDICARE COMPLIANCE TRAINING EMPLOYEES & FDR S. 2012 Revised

2012-2013 MEDICARE COMPLIANCE TRAINING EMPLOYEES & FDR S. 2012 Revised 2012-2013 MEDICARE COMPLIANCE TRAINING EMPLOYEES & FDR S 2012 Revised 1 Introduction CMS Requirements As of January 1, 2011, Federal Regulations require that Medicare Advantage Organizations (MAOs) and

More information

I. Policy Purpose. II. Policy Statement. III. Policy Definitions: RESPONSIBILITY:

I. Policy Purpose. II. Policy Statement. III. Policy Definitions: RESPONSIBILITY: POLICY NAME: POLICY SPONSOR: FRAUD, WASTE AND ABUSE COMPLIANCE OFFICER RESPONSIBILITY: EFFECTIVE DATE: REVIEW/ REVISED DATE: I. Policy Purpose The purpose of this policy is to outline the requirements

More information

The United States spends more than $1 trillion each year on healthcare

The United States spends more than $1 trillion each year on healthcare Managed Care Fraud and Abuse Compliance Guidelines I. Introduction The United States spends more than $1 trillion each year on healthcare representing approximately 15 percent of the gross national product.

More information

CMS ACO Proposed Regulations

CMS ACO Proposed Regulations CMS ACO Proposed Regulations May 2011 Proposed CMS ACO Regulations Proposed Regulations issued March 31, 2011 Comments due back June 6, 2011 Requires 3 year binding commitment Formal Legal Structure Required

More information

MODULE II: MEDICARE & MEDICAID FRAUD, WASTE, AND ABUSE TRAINING

MODULE II: MEDICARE & MEDICAID FRAUD, WASTE, AND ABUSE TRAINING MODULE II: MEDICARE & MEDICAID FRAUD, WASTE, AND ABUSE TRAINING 2 0 1 4 Introduction The Medicare and Medicaid programs are governed by statutes, regulations, and policies PacificSource must have an effective

More information

Establishing An Effective Corporate Compliance Program Joan Feldman, Esq. Vincenzo Carannante, Esq. William Roberts, Esq.

Establishing An Effective Corporate Compliance Program Joan Feldman, Esq. Vincenzo Carannante, Esq. William Roberts, Esq. Establishing An Effective Corporate Compliance Program Joan Feldman, Esq. Vincenzo Carannante, Esq. William Roberts, Esq. November 11, 2014 Shipman & Goodwin LLP 2014. All rights reserved. HARTFORD STAMFORD

More information

COMMENTARY. HHS Announces Next Generation ACO Model of Payment and Care Delivery. Potential Participants. Focus of the Next Gen ACO Model

COMMENTARY. HHS Announces Next Generation ACO Model of Payment and Care Delivery. Potential Participants. Focus of the Next Gen ACO Model April 2015 COMMENTARY HHS Announces Next Generation ACO Model of Payment and Care Delivery On March 10, 2015, the U.S. Department of Health and Human Services ( HHS ) announced the Next Generation Accountable

More information

OHIO HOSPITAL ASSOCIATION 2015 Annual Meeting. Accountable Care Organizations Comprehensive Integration Strategy

OHIO HOSPITAL ASSOCIATION 2015 Annual Meeting. Accountable Care Organizations Comprehensive Integration Strategy OHIO HOSPITAL ASSOCIATION 2015 Annual Meeting Accountable Care Organizations Comprehensive Integration Strategy ACO Development Market Conditions Increasing Economic pressures Consumerism Regulatory scrutiny

More information

The Fraud Enforcement and Recovery Act and Healthcare Reform: Implications for Compliance Initiatives and Fraud Investigations

The Fraud Enforcement and Recovery Act and Healthcare Reform: Implications for Compliance Initiatives and Fraud Investigations The Fraud Enforcement and Recovery Act and Healthcare Reform: Implications for Compliance Initiatives and Fraud Investigations Presented by: Robert Threlkeld, Esq. Holly Pierson, Esq. Paul F. Danello,

More information

Legal Issues to Consider When Creating a Health Care Business Model

Legal Issues to Consider When Creating a Health Care Business Model Legal Issues to Consider When Creating a Health Care Business Model Connie A. Raffa, J.D., LL.M. Business practices considered standard in other industries may in the health care industry be considered

More information

False Claims Act CMP212

False Claims Act CMP212 False Claims Act CMP212 Colorado Access is committed to a culture of compliance in which its employees, providers, contractors, and consultants are educated and knowledgeable about their role in reporting

More information

North American Partners in Anesthesia. Corporate Compliance Plan

North American Partners in Anesthesia. Corporate Compliance Plan North American Partners in Anesthesia Corporate Compliance Plan VERSION EFFECTIVE: JANUARY 2015 CONTENTS Introduction and Mission 1. Corporate Commitment to Compliance: Code of Conduct 2. Written Compliance

More information

C O N F I D E N T I A L A N D P R O P R I E T A R Y. Page 1 of 7 Title: FRAUD, WASTE, AND ABUSE POLICY

C O N F I D E N T I A L A N D P R O P R I E T A R Y. Page 1 of 7 Title: FRAUD, WASTE, AND ABUSE POLICY Page 1 of 7 1. Purpose As a Company that does business with U.S. state and federal government health care programs (such as Medicare and Medicaid), Hill-Rom is required to maintain a system of policies

More information

2015 Fraud, Waste & Abuse Prevention

2015 Fraud, Waste & Abuse Prevention Quality Independent Physicians, LLC Awareness Training 2015 Fraud, Waste & Abuse Prevention Fraud, Waste and Abuse (FWA) Training Objectives After completing this training you should be able to: Recognize

More information

Fraud, Waste & Abuse. UPMC Health Plan Quality Audit, Fraud, Waste & Abuse Department

Fraud, Waste & Abuse. UPMC Health Plan Quality Audit, Fraud, Waste & Abuse Department Fraud, Waste & Abuse UPMC Health Plan Quality Audit, Fraud, Waste & Abuse Department Definitions of Fraud, Waste & Abuse FRAUD: An intentional deception or misrepresentation made by a person or entity,

More information

PREVENTING FRAUD, ABUSE, & WASTE: A Primer for Physical Therapists

PREVENTING FRAUD, ABUSE, & WASTE: A Primer for Physical Therapists PREVENTING FRAUD, ABUSE, & WASTE: A Primer for Physical Therapists Available at: http://www.apta.org/integrity 2014 American Physical Therapy Association. All rights reserved. All reproduction or redistribution

More information

Touchstone Health Training Guide: Fraud, Waste and Abuse Prevention

Touchstone Health Training Guide: Fraud, Waste and Abuse Prevention Touchstone Health Training Guide: Fraud, Waste and Abuse Prevention About the Training Guide Touchstone is providing this Fraud, Waste and Abuse Prevention Training Guide as a resource for meeting Centers

More information

Compliance, Code of Conduct & Ethics Program Cantex Continuing Care Network. Contents

Compliance, Code of Conduct & Ethics Program Cantex Continuing Care Network. Contents Compliance, Code of Conduct & Ethics Program Cantex Continuing Care Network Contents Compliance, Code of Conduct & Ethics Program 1 What is the CCCN Code of Conduct? 2 Operating Philosophies 2 Employee

More information

Program Integrity (PI) for Network Providers

Program Integrity (PI) for Network Providers Program Integrity (PI) for Network Providers Purpose of Program Integrity Quality providers o Improved outcomes for consumers o Reduced oversight for provider o Confidence in network for LME-MCOs Financial

More information

Application & Implementation of ACO Waivers and Ongoing Compliance Issues

Application & Implementation of ACO Waivers and Ongoing Compliance Issues Application & Implementation of ACO Waivers and Ongoing Compliance Issues Presenter Todd A. Zigrang MBA, MHA, FACHE, ASA HEALTH CAPITAL CONSULTANTS Thursday, August 13, 2015 1:30 p.m. Hilton St. Louis,

More information

FAQs on the final ACO regulations

FAQs on the final ACO regulations - 1 - December 28, 2011 FAQs on the final ACO regulations By Peter A. Egan, Linn Foster Freedman, Carolyn J. Gabbay, Christopher P. Hampton, Lindsay Maleson, David A. Martland, Michele A. Masucci, Christopher

More information

Fraud, Waste and Abuse Page 1 of 9

Fraud, Waste and Abuse Page 1 of 9 Page 1 of 9 Overview It is the policy of MVP Health Care, Inc. and its affiliates (collectively referred to as MVP ) to comply with all applicable federal and state laws regarding fraud, waste and abuse.

More information

SAINT FRANCIS HEALTHCARE PARTNERS, INC. CORPORATE COMPLIANCE PLAN. Adopted by Resolution of the Board of Directors on August 28, 2012

SAINT FRANCIS HEALTHCARE PARTNERS, INC. CORPORATE COMPLIANCE PLAN. Adopted by Resolution of the Board of Directors on August 28, 2012 SAINT FRANCIS HEALTHCARE PARTNERS, INC. CORPORATE COMPLIANCE PLAN Adopted by Resolution of the Board of Directors on August 28, 2012 TABLE OF CONTENTS PAGE CORPORATE COMPLIANCE PLAN... 1 MISSION STATEMENT

More information

OSF Healthcare System Pioneer Accountable Care Organization (ACO) Compliance Plan

OSF Healthcare System Pioneer Accountable Care Organization (ACO) Compliance Plan OSF Healthcare System Pioneer Accountable Care Organization (ACO) Compliance Plan Approved: July 2012 TABLE OF CONTENTS Page Definitions...5 Introduction...8 Benefits of a Compliance Program... 10 Elements

More information

Health Law Section Spring Conference May 7, 2013 Scott S. Bell. parsonsbehle.com

Health Law Section Spring Conference May 7, 2013 Scott S. Bell. parsonsbehle.com ANTI-KICKBACK STATUTE AND STARK LAW UPDATE Health Law Section Spring Conference May 7, 2013 Scott S. Bell parsonsbehle.com Anti-Kickback Statute Don t pay for referrals! 2 Anti-Kickback Statute Prohibits

More information

SECTION 18 1 FRAUD, WASTE AND ABUSE

SECTION 18 1 FRAUD, WASTE AND ABUSE SECTION 18 1 FRAUD, WASTE AND ABUSE Annual FW&A Training Required for Providers and Office Staff 1 Examples of Fraud, Waste and Abuse 2 Fraud, Waste and Abuse Program Policy 3 Suspected Non-Compliance

More information

OIG Open Letter Regarding the Self-Disclosure Protocol: Further Refinements

OIG Open Letter Regarding the Self-Disclosure Protocol: Further Refinements 2009 American Health Lawyers Association April 17, 2009 Vol. VII Issue 15 OIG Open Letter Regarding the Self-Disclosure Protocol: Further Refinements By Ritu Kaur Singh, Frank E. Sheeder III, and Gerald

More information

COMPLIANCE PROGRAM GUIDANCE FOR MEDICARE FEE-FOR-SERVICE CONTRACTORS

COMPLIANCE PROGRAM GUIDANCE FOR MEDICARE FEE-FOR-SERVICE CONTRACTORS Department of Health and Human Services CENTERS FOR MEDICARE & MEDICAID SERVICES COMPLIANCE PROGRAM GUIDANCE FOR MEDICARE FEE-FOR-SERVICE CONTRACTORS March 2005 TABLE OF CONTENTS INTRODUCTION...3 ELEMENTS

More information

Medicare Shared Savings Program: Accountable Care Organizations. Centers for Medicare and Medicaid Services Final Rule Provisions

Medicare Shared Savings Program: Accountable Care Organizations. Centers for Medicare and Medicaid Services Final Rule Provisions Medicare Shared Savings Program: Accountable Care Organizations Centers for Medicare and Medicaid Services Final Rule Provisions The Centers for Medicare and Medicaid Services (CMS) published a final rule

More information

Fraud, Waste and Abuse Training. Protecting the Health Care Investment. Section Three

Fraud, Waste and Abuse Training. Protecting the Health Care Investment. Section Three Fraud, Waste and Abuse Training Protecting the Health Care Investment Section Three Section 1.2: Purpose According to the National Health Care Anti-Fraud Association, the United States spends more than

More information

Alphabet Soup: A Review of ACO Guidance from CMS, FTC, DOJ, OIG and IRS. November 10, 2011

Alphabet Soup: A Review of ACO Guidance from CMS, FTC, DOJ, OIG and IRS. November 10, 2011 Alphabet Soup: A Review of ACO Guidance from CMS, FTC, DOJ, OIG and IRS November 10, 2011 Final ACO Fraud & Abuse Waivers Daniel H. Melvin McDermott Will & Emery 312.984.6935 dmelvin@mwe.com November 10,

More information

Fraud, Waste and Abuse Prevention Training

Fraud, Waste and Abuse Prevention Training Fraud, Waste and Abuse Prevention Training The Centers for Medicare & Medicaid Services (CMS) requires annual fraud, waste and abuse training for organizations providing health services to MA or Medicare

More information

General Policy Statement and Standards on Prohibition on Self-Referrals, Kickbacks and Inducements to Refer. Refer to document abstract on Pulse

General Policy Statement and Standards on Prohibition on Self-Referrals, Kickbacks and Inducements to Refer. Refer to document abstract on Pulse POLICY Department: Corporate Compliance and Audit Services Mnemonic: COM Type: S Number: LL-010 Policy Title: General Policy Statement and Standards on Prohibition on Self-rals, Kickbacks and Inducements

More information

Stark, False Claims and Anti- Kickback Laws: Easy Ways to Stay Compliant with the Big Three in Healthcare

Stark, False Claims and Anti- Kickback Laws: Easy Ways to Stay Compliant with the Big Three in Healthcare Stark, False Claims and Anti- Kickback Laws: Easy Ways to Stay Compliant with the Big Three in Healthcare In health care, we are blessed with an abundance of rules, policies, standards and laws. In Health

More information

Crosswalk: CMS Shared Savings Rules & NCQA ACO Accreditation Standards 12/1/2011

Crosswalk: CMS Shared Savings Rules & NCQA ACO Accreditation Standards 12/1/2011 Crosswalk: CMS Shared Savings Rules & NCQA ACO Accreditation Standards 12/1/2011 The table below details areas where NCQA s ACO Accreditation standards overlap with the CMS Final Rule CMS Pioneer ACO CMS

More information

Fraud, Waste and Abuse: Compliance Program. Section 4: National Provider Network Handbook

Fraud, Waste and Abuse: Compliance Program. Section 4: National Provider Network Handbook Fraud, Waste and Abuse: Compliance Program Section 4: National Provider Network Handbook December 2015 2 Our Philosophy Magellan takes provider fraud, waste and abuse We engage in considerable efforts

More information

Minimum Performance and Service Criteria for Medicare Part D

Minimum Performance and Service Criteria for Medicare Part D Minimum Performance and Service Criteria for Medicare Part D 1. Terms and Conditions. In addition to the other terms and conditions of the Pharmacy Participation Agreement ( Agreement ), the following

More information

CORPORATE COMPLIANCE PROGRAM

CORPORATE COMPLIANCE PROGRAM CORPORATE COMPLIANCE PROGRAM BACKGROUND AND POLICY: The Oakwood Accountable Care Organization, LLC. ( ACO ) corporate policy relating to compliance with applicable laws and regulations is embodied in this

More information