Compliance Program - America's ACO

AMERICA’S ACO COMPLIANCE PROGRAM

NOTE: Throughout the AMERICA’S ACO Compliance Program Description the reference to “staff” refers to executive, management and support staff of the ACO, and the reference to “affiliated contracted entities” refers contractors of the ACO, ACO participants, ACO providers/suppliers, and other individuals or entities performing functions or services related to ACO activities.

The AMERICA’S ACO Compliance Program is designed to promote adherence to appropriate standards of business conduct throughout all aspects of the organizations operation and to ensure conformance with applicable federal, state, and local statutory and regulatory obligations by the organization and its staff and affiliated contracted entities. The Compliance Program is designed with direct reference to the most recent applicable directives from CMS regarding the Medicare Shared Savings Program (MSSP) (42 CFR § 425.300 – Compliance plan), and directives from of the U.S. Office of the Inspector General regarding the detection and control of fraud, waste, and abuse.

The fundamental goals of the America’s ACO Compliance Program include:

Ensuring that the ACO’s Board of Directors establishes a commitment to the development of and adherence to a comprehensive Compliance Program that permeates and impacts all operations of the organization.
Establishment of an infrastructure within the America’s ACO organization for the implementation of the Compliance Program, including the installation of a Compliance Officer and the establishment of a formal Compliance Committee.
Organizational commitment of necessary and sufficient resources to ensure the effective implementation of the Compliance Program.
Development of a Code of Ethics and Standards of Conduct to be acknowledged and adhered to by ACO staff and affiliated contracted entities
Development of compliance program policies and procedures applicable to all of the organizations operations and lines of business.
Formally displaying the America’s ACO Compliance Program narrative and associated policies and procedures on the AMERICA’S ACO website.
Facilitate understanding of the America’s ACO Compliance Program on behalf of ACO staff and affiliated contracted entities through training mechanisms that ensure that the Compliance Program and corresponding policies and procedures are clearly understood and applied within and throughout the operational structure of the organization.
Creation of channels of communication within the organization for reporting suspected violations of AMERICA’S ACO Code of Ethics and Standards of Conduct, compliance policies and procedures, fraud, waste, and abuse policies and procedures, and/or other pertinent regulatory obligations, without fear of reprisal.
Prompt investigation of all credible reports of suspected violations of AMERICA’S ACO Code of Ethics and Standards of Conduct, compliance policies and procedures, fraud, waste, and abuse policies and procedures, and/or regulatory obligations of the company to state and federal agencies and organizations.
Implementation of routine audits of America’s ACO operations to assess compliance with applicable established and board approved policies and procedures and state and federal regulatory requirements and expectations.
Imposition of accountability for violations of America’s ACO policies and procedures and regulatory obligations under the MSSP (including department directors and managers who condone or unreasonably fail to prevent improper conduct), and the administration of fair and prompt disciplinary action.

A. Compliance Infrastructure

The America’s ACO Compliance Program is tailored to the requirements of the CMS Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO). The Compliance Officer directs the Compliance Program and reports directly to the Board of Directors of the organization. The Compliance Officer and his or her staff have responsibility for the oversight of regulatory compliance, including compliance policy development, staff education and training on the Compliance Program, and investigations of alleged regulatory and policy violations, and compliance monitoring and auditing of operations.

America’s ACO also supports a formal Compliance Committee that oversees the operations of the Compliance Program. The Compliance Committee is composed of senior executives of America’s ACO, the America’s ACO Medical Director, and at least two representatives from the participating provider network. The Committee meets at least bi-annually and is chaired by the Compliance Officer. All Committee activities are recorded in minutes that are preserved in files under the direct control of the Compliance Officer.

B. Code of Ethics and Standards of Conduct

The America’s ACO Code of Ethics and Standards of Conduct reflect a commitment to operate in accordance with accepted standards of business conduct, the organizations established policies and procedures, and applicable state and federal laws and regulations. All staff of the ACO and affiliated contracted entities sign a written acknowledgement that they have reviewed the Code of Ethics and Standards of Conduct and will carry out their respective responsibilities in compliance with the operational policies and procedures of America’s ACO, and the state and federal laws and regulations that govern the operation of the organization. To facilitate the review by aligned parties, the Code of Ethics and Standards of Conduct are to be posted on the America’s ACO website.

C. Compliance and Fraud, Waste, and Abuse Training

The Compliance Officer or his/her designee is responsible for organizing and implementing initial and annual mandatory compliance and fraud, waste, and abuse training for all staff of the ACO and affiliated contracted entities. The training includes a review of:
1) The America’s ACO Compliance Organization and associated policies and procedures
2) The America’s ACO Code of Ethics and Standards of Conduct
3) The Fraud, Waste and Abuse Training Module posted on the America’s ACO website
4) Obligations and procedures staff and affiliated contracted entities of the ACO to report suspected compliance violations and/or fraud, waste, and abuse.

D. Reporting Compliance Concerns

It is the obligation of all staff and affiliated contracted entities to the ACO to report compliance concerns. Investigation of compliance inquiries or reports is the responsibility of the Compliance Officer. The Compliance Officer is responsible for:

Ensuring all investigations are carried out in a fair and unbiased manner.
Ensuring that the individual making the complaint and/or reporting a compliance concern is treated fairly, and that their confidentiality is protected to the extent the law allows, and that no retaliation takes place.

If an investigation by the Compliance Officer confirms the existence of a compliance issue and/or fraud, waste, and abuse, he or she works closely with ACO staff and affiliated contracted entities to resolve the issue, take necessary corrective action or actions, and ensure appropriate disciplinary action.

Consistent with recommendations by the OIG, America’s ACO has established a Compliance and Fraud, Waste, and Abuse Hotline. All staff and affiliated contracted entities of the ACO are encouraged to report suspected violations of law or the organizations policies through a dedicated Hotline. Caller anonymity may be requested. America’s ACO policy prohibits retaliation against anyone who in good faith reports a legal or compliance concern. Hotline calls are reviewed by the Compliance Officer and followed through with assistance, if necessary and appropriate, from the executive and management staff.

E. On-Going Risk Assessment

The Compliance Officer is responsible for working with the America’s ACO Board of Directors and the Compliance Committee to identify risk areas of operation requiring the establishment or enhancement of internal controls, policy revisions, or improvements in compliance training. Risk areas represent those areas of operation in which compliance concerns typically emerge in the operation of an ACO. These risk areas include, but are not limited to:

Contracts
Medicare Beneficiary Benefits and Protections, including PHI.
Use of Claims Data
Provider Contracts
Administrative Management Contracts
Quality Assurance and Outcome Performance Monitoring and Reporting

F. Internal Audits

As part of the on-going operation of the Compliance Program, the Compliance Officer may elect to proactively conduct periodic audits of operational components of the organization. The Compliance Officer is authorized by the America’s ACO Board of Directors to conduct such audits and to contract for the use of external audit resources as warranted.

The intent of the audits are to assess baseline regulatory compliance performance in select operational areas of the organization. Audit findings and recommendations are reported to the Board of Directors, and the Compliance Committee. If corrective action is recommended, such action becomes part of the audit report. The Compliance Officer is responsible for follow-up audits to verify implementation of corrective action or actions, as indicated.

G. Screening for Excluded Parties

America’s ACO screens current and new employees, independent contractors, independent providers, and vendors against the Office of Inspector General’s List of Individuals/Entities Excluded from Federal Programs. The company will not engage a person or company that is excluded from participating in federally funded health care programs or government procurement programs. America’s ACO also validates the professional licenses and/or certifications of certain employee’s categories as required by state and federal laws and regulations.

H. Fraud, Waste, and Abuse Policy

America’s ACO has developed a Fraud, Waste and Abuse policy. The Fraud, Waste, and Abuse policy provides specific instructions for detection, investigation, and reporting of insurance fraud, including but not limited to internal fraud, premium fraud, health care fraud, insolvency fraud, application fraud, and pharmacy fraud. The Fraud, Waste, and Abuse policy is part of America’s ACO overall Compliance Program. As such, the established Code of Ethics and Standards of Conduct of the Compliance Program fully apply to fraud, waste, and abuts prevention, detection and correction.

All staff and affiliated contracted entities of theare advised of their responsibility to report suspected fraudulent activity to the Compliance Officer and/or CMS. The Compliance Program established policy and procedure regarding reporting of compliance concerns fully applies with regard to reporting suspected fraudulent activity.

I. Disciplinary Action

Per policy, America’s ACO will provide relevant state and federal regulatory entities (e.g., CMS) the right under certain conditions to request access to or copies of America’s ACO books, records, and other information as well as access to staff members of America’s ACO . Further, America’s ACO allows state and federal regulatory entities timely access to or copies of its’ books, records and other information as well as access to staff members as is required by laws, regulations, guidelines or other regulatory requirements.

J. Access by Regulatory Agencies to FPTC Books and Records

K. Delegated Entity Oversight

America’s ACO may delegate to a contracted entity the authority to perform specified functions on its behalf. Prior to delegation, the delegated entity must demonstrate that they meet America’s ACO standards and CMS standards regarding the Medicare Shared Saving Program as promulgated and defined in systematic process is followed for engaging contractually with a delegated entity and on-going oversight of delegated entities.

L. CMS Review of Marketing Materials

America’s ACO has a formal process to ensure that all marketing and communication materials directed at Medicare beneficiaries are submitted, reviewed, and approved by CMS prior to distribution and use by beneficiaries. This process includes procedures for recording of approved materials by material type and date of approval by the Compliance Officer.