Introduction: ACO Compliance Plan

A2 ACO (the ACO) is an Accountable Care Organization (ACO). The ACO is committed to conducting its business with the highest level of integrity and in accordance with all applicable federal and state laws, regulations and standards. It is the policy of the ACO to ensure that any improper and/or unethical behavior is identified, reported, and corrected as soon as it is identified. The ACO requires that all ACO employees, Participants, Provider/Suppliers, and all other individuals or entities providing functions or services related to ACO Activities (hereafter referred to as ACO Related Individuals) follow the ACO’s policies and procedures.

ACO Activities means activities related to promoting accountability for the quality, cost, and overall care for a patient population of aligned Medicare fee-for-service beneficiaries (Beneficiaries), including managing and coordinating care for Beneficiaries; encouraging investment in infrastructure and redesigned care processes for high quality and efficient service delivery; or carrying out any other obligation or duty of the ACO under the Medicare Shared Savings Program.

The ACO has established practices and procedures to ensure that the ACO is in compliance with applicable federal and state laws and regulatory requirements. This document along with the ACO’s compliance policies and procedures, collectively comprise the ACO’s Compliance Program. This Program is intended to prevent, detect, and correct non-compliant operational practices and improper and/or unethical conduct impacting the ACO.

With respect to ACOs, two Federal agencies have issued guidance regarding compliance programs: the Centers for Medicare & Medicaid Services (CMS) and the Office of the Inspector General (OIG). CMS requires that ACO compliance plans include:

A designated compliance official or individual who is not legal counsel to the ACO and 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 ACO Related Individuals to anonymously report suspected problems related to the ACO to the compliance official;

Compliance training for the ACO, its Next Generation Participants, and Preferred Providers; and, A requirement for the ACO to report probable violations of law to an appropriate law enforcement agency.

The ACO’s Compliance Program has been developed and managed to ensure compliance with these requirements, as well as any additional federal and State laws, guidelines and regulations.

Section I: Compliance Officer Role & Responsibilities

The ACO’s Board of Directors is responsible for appointing the Compliance Officer and approving the Compliance Plan. The Compliance Officer is responsible for management and oversight of the Compliance Program and for ensuring that the ACO remains in compliance with all federal and state laws, regulations and requirements. The ACO Compliance Officer does not serve as legal counsel to the ACO and reports directly to the Board of Directors, at least four (4) times per year, and has responsibility for:

Maintaining and overseeing the ACO’s Compliance Program, including compliance with all ACO policies and procedures and ensuring all Compliance Program documents are reviewed and updated as needed, but no less than annually.
Monitoring and oversight of operational areas to ensure compliance with all federal and state laws, regulations, and standards.
Working with ACO leadership to correct any deficiencies found as part of compliance monitoring and oversight to ensure that issues do not recur.

Acting as compliance liaison between regulatory bodies and the ACO. This includes, but is not limited to, ensuring timely dissemination of important communications from CMS which are specific to compliance.
Assisting the ACO’s counsel and management with coordination of, and response to, government audits and/or investigations of the ACO.

Ensuring appropriate education and training around compliance requirements for all ACO Related Individuals.

The Board of Directors retains oversight of the Compliance Program through regular reporting from the Compliance Officer. These reports include standard reporting on Compliance activities and requirements, as well as identify any potential areas of concern. Written reports are provided quarterly, with in-person reports as needed or requested by the Board of Directors or the Compliance Officer.

Section II: Mechanisms for Identifying and Addressing Compliance Concerns

The ACO has mechanisms in place to identify and address compliance problems related to its operations and performance. These include: (1) Policies and Procedures, (2) A robust Monitoring & Oversight Program, (3) Use of Corrective Action Plans, and (4) Use of consistent disciplinary actions.

Policies and Procedures

In order to articulate the ACO’s compliance and ethical standards and its commitment to comply with all applicable federal and state laws and regulations, the ACO has established written policies and procedures. These policies describe compliance expectations as well as how to report, investigate and resolve potential issues or concerns. The Compliance Officer is responsible for ensuring that appropriate policies are in place to further clarify the goals and standards outlined in this Compliance Plan and that those policies and procedures are reviewed as needed, but at least annually. Compliance Policies & Procedures will be made available to all ACO Related Individuals upon hire or contracting, and upon request thereafter. When significant changes are made, appropriate ACO Related Individuals will be notified and/or trained on the new processes as needed. Documentation of any training will be maintained in accordance with applicable record retention standards and the policies of the ACO.

Monitoring & Oversight Program

The Compliance Officer will work to maintain a robust Monitoring & Oversight Program. This program will be used to ensure compliance with the ACO’s policies and procedures. The Monitoring and Oversight Program will include passive continuous monitoring and reporting as well as formal pro-active monitoring and auditing of operational areas. Formal auditing will be prioritized based on risk to the organization and potential for impact on Beneficiaries and will include document review as well as on-site review of actual processes. The Compliance Officer will provide reports to the Board of Directors..

Corrective Action Plans

Corrective Action Plans will be utilized to ensure that any identified issues are corrected and will not recur. The Compliance Officer will work with the impacted operational areas to develop the Corrective Action Plan. Any Corrective Action Plan will include creation and documentation of internal controls and policies and procedures that will be put into place to correct the issue and prevent it from occurring again. The Corrective Action Plan will also include a plan for monitoring to ensure that the implemented changes are effective, as well as recommendations for disciplinary action and sanctions, as appropriate. The Compliance Officer will report any Corrective Actions Plans at least quarterly. These reports will include any Corrective Action Plans opened or closed during the previous quarter, as well as any identified concerns with recurring compliance issues.

Disciplinary Actions

The ACO requires all ACO Related Individuals to comply with all applicable terms of the Medicare Shared Savings Program and all applicable statutes regulations, and guidance, including without limitation: (a) federal criminal laws; (b) the False Claims Act (31 U.S.C. § 3729 et seq.); (c) the anti-kickback statute (42 U.S.C. § 1320a-7b(b)); (d) the civil monetary penalties law (42 U.S.C. § 1320a-7a); and (e) the physician self-referral law (42 U.S.C. § 1395nn). ACO Related Individuals who violate relevant laws and regulations established by governmental agencies, and/or policies as established by the ACO, may be subject to disciplinary action in accordance with ACO policies and procedures or any relevant contractual arrangement. Violations of ACO policies could result in termination of participation in the ACO. The ACO may also report such violations to applicable regulatory or licensing authorities, which may result in loss of licensure, fines, exclusion from federally funded programs, and/or imprisonment, as determined by the governing enforcement agency.

All ACO Related Individuals are expected to cooperate with any and all investigations relating to non-compliant activity. The investigations can be conducted by the Compliance Officer, the Board of Directors and/or their designated representatives. If appropriate, ACO Related Individuals will be notified of governmental investigations in which they may be required to provide assistance.

Section III: Methods for Reporting to Compliance

In order to have an effective Compliance Program, ACO Related Individuals and Beneficiaries must have access to a means by which they may report concerns related to compliance and privacy.. Failure to report suspected unethical or unlawful conduct is harmful to the integrity of the ACO and is a potential violation of the ACO’s Compliance Program. In addition, they must understand that they will not be retaliated against if they report such activities. It is the policy of the ACO that no individual who reports in good faith will be retaliated against. This policy is clearly outlined in the ACO’s policies and procedures as well as the Compliance Training, which are distributed to every ACO Related Individual upon hire or contracting, and at least annually thereafter. Compliance Program documents are always available upon request.

Potential compliance issues and concerns can be reported directly to the Compliance Officer, via email or through the Compliance Hotline. Contact information for these reporting mechanisms can be found in Section VII of this Compliance Plan. Compliance concerns can also be reported through the supervisory channels within the ACO. The Compliance Officer is responsible for conducting appropriate investigations into reports received through any of these channels and maintaining a log of all reports received and any investigation or follow-up activities conducted in response to the report. The Compliance Officer is responsible for determining whether he or she believes a violation has occurred and is free to raise concerns to the Board of Directors without fear of retaliation.

Reporting Directly to the Compliance Officer

ACO Related Individuals are instructed that the Compliance Officer is available to receive any reports regarding potential compliance issues on a confidential basis. These reports may be made in person or by calling or emailing the Compliance Officer directly. Where possible, the Compliance Officer will maintain the confidentiality of the individual making the report. If it is not possible to maintain confidentiality, the Compliance Officer will inform the reporter prior to disclosure and will include: (1) the reason for sharing, and (2) the extent to which their information will need to be shared.
Reporting through ACO Supervisory Channels

If they prefer, ACO Related Individuals are also able to contact their immediate supervisor when non-compliant activity is suspected. This report should be made immediately upon identifying the issue. The supervisor will report this to the Compliance Officer for further investigation and reporting to the Board of Directors of the ACO, as appropriate. If the individual feels as though their immediate supervisor did not adequately address the complaint, they may still go directly to the Compliance Officer via any of the other reporting methods.

Anonymous Reporting

The ACO has also set up an anonymous reporting tool available for all ACO Related Individuals and Beneficiaries. This tool is available 24 hours a day, 7 days a week, and allows for individuals to report potential compliance concerns anonymously. The access information for this tool is listed in Section VII of this Compliance Plan, communications regarding ACO Compliance Training, and on the ACO’s website.

Investigation & Follow Up

The Compliance Officer is responsible for conducting appropriate investigation and follow-up based on reports received. The activities undertaken may vary based on the facts of the report. The Compliance Officer is free to conduct any activities deemed necessary for him or her to determine whether or not a violation has occurred, but will include, at a minimum, the interview of any individuals related to the incident. The Compliance Officer will maintain a log detailing the report, the investigation, and any disciplinary or corrective actions. The ACO’s Board of Directors will receive a report based on this log at least quarterly.

Section IV: Education & Training

The ACO requires that all ACO Related Individuals complete Compliance training upon hire or contracting and on an annual basis thereafter. The training emphasizes the ACO’s commitment to making compliance with federal and state requirements a top priority. This training includes, but is not limited to training on the ACO Compliance Program, Privacy Requirements, and Fraud, Waste and Abuse (FWA) laws.
The Compliance Officer is responsible for ensuring the appropriate documentation of training completions and retention of training records. The Compliance Officer is also responsible for ensuring that this training is reviewed and updated as needed, but no less than annually. Details around how the training is delivered and how the ACO ensures completion of the training for all ACO Related Individuals are included in the ACO’s Compliance Training Policy and Procedure.
The ACO also understands the importance of informal compliance communication to ensure consistent reminders and education related to Compliance. The Compliance Officer may conduct informal training and education programs through the use of newsletters or emails used to remind ACO Related Individuals and Beneficiaries of compliance resources and reporting obligations.

Section V: Reporting to Law Enforcement

It is the policy of the ACO to ensure that all probable violations of law are reported to an appropriate law enforcement agency. The ACO Compliance Officer is responsible for reviewing any identified compliance concern to determine whether they may be probable violations of law. If, during any Compliance monitoring or investigation, it is found that any ACO Related Individual has undertaken activity that would constitute a probable violation of law, the Compliance Officer will work with the ACO’s general counsel to ensure that the appropriate law enforcement agencies are notified in a timely manner. The Compliance Officer has the authority to report any misconduct to CMS, its designee, and law enforcement.
Section VI: Review and Approval of Compliance Plan

Since laws and regulations are constantly implemented and modified, it is imperative that this Compliance Plan be reviewed and modified periodically. The ACO Compliance Officer will review the Compliance Plan no less than annually to ensure that it adheres to any new or modified laws and regulations. Any substantive changes to the Compliance Plan will be reviewed and approved by the Board of Directors .

Section VII: Compliance Officer Contact Information

ACO Compliance Officer: Dana Williams, MSHI, RHIA, CHC, CHP
dana.williams@baptist-health.org
ph (501) 202 6776
fx (501) 202 1115

ACO Anonymous Reporting Tool:
(833) 210 3963