Raising the Bar: How to Operate without Program Conditions

1. Raising the Bar: How to Operate without Program Conditions Preventing and Resolving the Most Frequent HRSA Program Conditions Alabama Primary Health Care Association

2. Program Compliance: Laying the Groundwork • Foundation of health centers existence is compliance with core program requirements • Session objectives • Review compliance areas and expectations • Review most frequent compliance conditions issued by HRSA • Review strategies for resolving conditions Alabama Primary Health Care Association

3. Program Compliance: Laying the Groundwork • OIG has more finances and resources than ever before for program audits; GAO reports need for enhanced HRSA oversight and compliance accountability • Compliance must be demonstrated through documentation and practice Alabama Primary Health Care Association

4. Rules of Contracting • Health centers have a contract with HRSA for funding; sets forth requirements for both HRSA and health centers. • Health centers agree to comply with federal program requirements when applications are submitted and funded. • Compliance must become as significant as accreditation standards

5. Rules of Contracting • HCs are bound to comply with federal program requirements even if the federal requirement exceeds state law and/or regulations. • Noncompliance will result in the issuance of a program condition; must be resolved quickly and fully to avoid loss of federal funding.

6. Program Compliance • HC boards, leadership and staff must know, understand and ensure compliance with each program requirement or risk loss of funds. • Must DEMONSTRATE compliance with each requirement; there is NO presumption of compliance and are NO waivers for compliance • Four categories of Compliance: Need, Services, Finance and Management, and Governance

7. Program Conditions • Conditions are issued by HRSA when it has determined a HC is noncompliant in one or more program requirement areas. • Conditions are issued when noncompliance is identified; even if the compliance matter is resolved while auditors are still on-site. • Details matter—must understand the details of compliance

8. Program Conditions • Most conditions issued by HRSA are documentation issues; includes failure to document appropriately, accurately, timely, and consistently • Any unresolved condition present an immediate jeopardy for the health center • Loss of federal status and funds are the result of failing to comply and quickly address any condition

9. A Quick Review: Need • Need Requirements • Must demonstrate and document the needs of its target population, updating when appropriate • Needs assessment must be written and be based on current data • Must be reviewed and approved annually by the Board • Must prioritize needs and establish action steps for addressing the need

10. A Quick Review: Need • Need Requirements • Must address health disparities, access to care, barriers to care and health status indicators • Must describe service area, target population and patients

11. Causes for Common Conditions: Need Program Condition Failure of Board to review and approve annually; failure to document in all required areas (previous slide) Compliance Strategy Board must review and approve a current needs assessment annually as part of the overall organizational assessment process; MUST document review and approval in meeting minutes

12. A Quick Review: Services • Required and Additional Services • Staffing • Accessible Hours of Operations/Locations • After Hours Coverage • Hospital Admitting Privileges and CoC • Sliding Fee Discount Program • QI/A Plan

13. A Quick Review: Required and Additional Services • Required and Additional Services – provide all mandatory services either directly or indirectly. Indirect services may be provided by fee arrangement or by referral. • Must have written agreements with all required provisions for any services not provided directly

14. Causes for Conditions: Required and Additional Services • Lack of provision of required services; most common examples are OB/GYN, mental health, substance abuse, and dental • Lack of or noncompliant written contractual agreements for services provided indirectly

15. A Quick Review: Staffing Requirement • Staffing – HCs must be appropriately staffed for size and needs; staff should have written job descriptions that match daily responsibilities. • Staff should be assigned in a reasonable manner given organizational needs and priorities (HIT, QI, other) • Ensure appropriate licensing, credentialing and evaluation • Management alignment with priorities and reasonable organizational structure • Written, board approved policies consistent with operational policies and bylaws • Productivity should be reviewed

16. Causes for Common Conditions:Staffing Requirement • Absence, incomplete or inaccurate staffing job descriptions • Lack of written policies and procedures related to personnel/HR • Lack of appropriate staffing levels given organizational priorities • Lack of appropriate organizational structure, evaluation structure, pay schedules and ranges

17. A Quick Review: Accessible Hours Operations/Locations • Accessible Hours of Operations and Locations – must demonstrate “adequate access” including hours of operations and site locations. • Board must review and approve (document) • Adequately post hours and ensure patients are aware of locations and hours

18. Causes for Common Conditions:Accessible Hours/Locations • Failure to document board approval of hours of operation and site locations • Failure to provide adequate notice to patients of hours of operation and/or locations • Actual hours of operation inconsistent with advertised hours/locations • Inconsistent signage of hours of operation

19. A Quick Review: After Hours Coverage • After Hour Coverage – must provide adequate and accessible coverage after normal office hours. • Requires notice to patients of how/when to access • Requires written agreement if coverage is provided outside of the organization • Requires written policies approved by Board

20. Causes of Common Conditions: After Hours Coverage • Failure to provide adequate notice to patients • Failure to document board approval • General referrals to ER through recorded messaging

21. A Quick Review: Hospital Privileges and CoC • Hospital Admitting Privileges and Continuity of Care – must have written and detailed agreements for hospital care, discharge planning, patient tracking and how CoC is ensured • Written agreements must address how patients are tracked and information is shared • Written agreements must consider FTCA issues and requirements of HC providers while on site at hospital or risk loss of coverage

22. Causes of Common Conditions: Hospital Admitting Privilege & CoC • Lack of detailed, written agreement • Lack of transition communication and plan

23. A Quick Review: Sliding Fee Program • Sliding Fee Program – system of providing discount program to all patients < 200% FPL for all HC services; discount program posted for patient awareness; no denial of care if unable to pay. Schedule of fees based on “locally prevailing rates or charges to cover reasonable costs” and corresponding schedule of discounts

24. Sliding Fee Discount Considerations • Full discounts for patients < 100% FPL; conditional imposition of nominal fee • Requires annual review and approval of fee schedule by Board • Requires annual adjustment to SF schedule based on federal updates; review and approval by Board • Requires policies related to eligibility process and application of SF reviewed and approved annually by Board

25. Sliding Fee Discount Considerations • Demonstrate availability of discount program to all patients under the FPL limit; not just uninsured patients • Demonstrate patient notice and availability of discount across all services; not just medical encounters • Demonstrate policies surrounding nominal fee; reviewed and approved annually by Board

26. Causes for Common Conditions: Sliding Fee Discount • Failure to annually update, board review and approval of fee schedule, SF FPL and policies • Inconsistent application of discount to insured patients • Failure to apply discount to all services; beyond medical encounter • Inadequate signage and patient notice of availability of discount program, eligibility requirements, and process • Failure to document, review and have board approval on the establishment of nominal fee

27. A Quick Review: QI/A Plan • QI/Assurance Plan • Formal, detailed, plan based on well developed policies and procedures • Must address clinical, operational, finance and budget, staffing, patient/community relations • Define performance metrics in clinical, operational, financial, staffing, patient/community relations • Formal and continuous training plan • Continued engagement of board, management, clinical team and support staff • Data driven; collection, analysis, review, training, repeat

28. Critical QI/A Components • Peer Review and Utilization review • Written QI committee member roles • Patient satisfaction surveys • Employee satisfaction surveys • State and Federal regulation compliance • Evidence-based/best practice standards

29. Critical QI/A Components • Formal policies, procedures, training plan, reporting, performance review with individual providers and non clinical staff • Risk management program • Meaningful Use and Information Exchange • EHR adoption • PCMH and other accreditation

30. Causes for Common Conditions: QI/A Plan • Lack of organized, detailed QI plan • Lack of disciplined, physician led activities • Lack of board engagement • Inconsistent reflection of actual QI activities with written QI Plan • Failure to establish key operational, financial, and clinical performance measures • Failure to integrate data driven approach into QI Plan

31. A Quick Review: Management and Finance • Key Management Staff • Contractual/Affiliation Agreements • Collaborative Relationships • Financial Management and Control Policies • Billing and Collections • Budget • Program Data Reporting System • Scope of Project

32. A Quick Review: Management and Finance • Key Management Staff – appropriate for size and need including CEO/ED, CMO, finance and billing. Key staff should be employed by HC. • HRSA must be notified of CEO/ED transition and review final candidates before position offering. • Must include written staffing titles, job responsibilities, reporting relationships, procedures for performance evaluations, and pay scales

33. Causes for Related ConditionsKey Management Staff • Organizational structure and supervision are inconsistent with written job descriptions, written policies • Lack of written position descriptions reflecting actual responsibilities • Lack of appropriate evaluations

34. A Quick Review: Contractual/Affiliation Agreements • Contractual/Affiliation Agreements – written agreements between HC and other providers for required and additional services. • Board must review and approval all contractual agmts. • Must maintain governing control • Must demonstrate HC has made and will continue to make very reasonable effort to establish agreements • Not enough to have verbal agreements • Not enough to demonstrate practice of referrals, indirect service provision • Must include required contract provisions

35. Required Contractual Provisions Must document in agreement: • Description of services to be provided • Times, locations services will be available • How payment/reimbursement will be made (by HC, establishment of sliding fee) • Nondiscrimination based on ability of a patient to pay

36. Required Contractual Provisions • Maintain HC governing control • Requirement to maintain appropriate systems, records and access to information • How information will be exchanged to ensure continuity of care • Require compliance with federal regulations • Termination clause for breach

37. Causes for Common Conditions: Contractual/Affiliate Agreements • Lack of a written agreement • Absence of required provisions • Lack of evidence of “all reasonable effort” • Create documentation of process of obtaining appropriate agreements even if unsuccessful

38. A Quick Review: Collaborative Relationships • Collaborative Relationships – required to demonstrate collaborative practice at community level within the service area. LOS required from any other HC in the service area for applications; explain why if not obtained.

39. A Quick Review: Collaborative Relationships • MOAs include community providers including: Hospitals RHC Mental Health Providers SA Providers Case Management ASO Private Practice ADPH Emergency Response (EMA) Others

40. Causes for Common Condition:Collaborative Relationships Cause for Condition: Absence of collaborative agreements or demonstrated reasonable attempt to establish; lack of purpose, objectives for the collaborative relationship Compliance Strategy Engage with community of care; reach out for formal agreements and practical daily relationships

41. A Quick Review: Financial Management and Control • Financial Management and Controls – accounting and internal control systems appropriate to size and complexity of organization • Ensure financial controls are in place • Produce annual budget reflecting goals and policies • Include board approved reports and investment policies • Monthly and quarterly review of financial reports • Review of audited statements • Review, approval, and revisions of budget periodically • Monitor cash flow

42. Financial Management and Control • Monthly financial statements reviewed by Finance Committee and board and documented in minutes • Document all financial policies and procedures • Board must demonstrate clear awareness of HC finances • Reasonable levels of AP, AR • Written, board approved cash disbursement and procurement policies and procedures

43. Common Causes for Conditions: Financial Management and Controls • Failure to document board review and adoption of finance and control policies • Failure to document board approval of auditor • Failure to document board review and approval of annual audit report, findings, corrective action if applicable • Failure to use and document activities of Finance Committee • Lack of understanding of organizational finances among board members

44. A Quick Review: Billing and Collection • Billing and Collection – must maintain systems that maximize collections and reimbursement including TP, SF, co-pays, deductibles, write offs • Billing and collection policies must be reviewed and approved by the board (document)

45. A Quick Review: Billing and Collection Required elements of B/C policies: • Staff responsible for B/C process • Frequency statements are sent to patients including new charges, old balances, total amt due • Plan for placing accounts on restriction if account is past 120 days without pmt effort • Process for writing off bad debt • Establishment of installment plan

46. Causes for Common ConditionsBilling and Collection • Absence of written policies and procedures • Incomplete or unapproved policies • Written policies that are inconsistent with practices and financial records • Failure to effectively manage AR in a timely manner

47. A Quick Review: Budget • Budget – annual budget based on accurate information and approved by the Board and applicable committee; includes approved business plan to accomplish budget goals • System/report to track variances and associate analysis • Monthly budget presentation to Board and Finance Committee

48. Compliance Issues • Lack of documentation of Board review and approval • Lack of appropriate use of Finance Committee and documented activities • Inaccurate or unrealistic budget construction • Lack of budget management/oversight • Lack of general understanding by Board of organizational budget and related issues

49. A Quick Review: Program Data Reporting System • Program Data Reporting System – requires systematic approach to data reporting of clinical, operational and financial data • Includes PMS, EHR, and other • UDS and beyond • Must document use of data in management and board decision making process • Must incorporate data reporting system into strategic planning process

50. Data Reporting System Issues • Failure to utilize reporting tools for key operational, financial and clinical measures • Failure to review data and act upon indicators in key performance areas • Failure to use reporting system as platform for strategic plan, business plan,