Impressing the Judges Performance and Compliance in an Environment of “Presumed” Non-Compliance

1. Impressing the JudgesPerformance and Compliance in an Environment of “Presumed” Non-Compliance Roger L. Bates Managing Member 9/27/12

2. Impressing the Judges Session Overview Review HRSA Site Visit Guidance for conducting operational and compliance related to the 19 core program requirements. Review FTCA program and compliance

3. Heightened Compliance Reviews • Funding for the Health Center Program has increased; doubled from approximately $1.3 billion to about $2.8 billion, FY 2002-FY2012. • Additional $2 billion through the American Recovery and Reinvestment Act of 2009 • $2.2 billion HRSA received through the Patient Protection and Affordable Act.

4. Strings Attached To continue receiving program funds, health center grantees must demonstrate compliance with core program requirements. HRSA groups these 19 program requirements into four broad categories: patient need, the provision of services, management and finance, and governance.

5. Oversight

6. HRSA Oversight HRSA relies on three main methods to oversee Grantee compliance with the 19 key program requirements: • Compliance reviews • Site visits 3. Routine communications

7. Beware: Stricter Scrutiny On June 21, 2012, members of the U.S. Congress released a Government Accountability Office (GAO) report concluding that the Health Resources and Services Administration (HRSA) does not adequately oversee grantee compliance with the federal Health Center Program requirements. The congressional representatives also sent HRSA a letter calling for immediate action to ensure more effective management of the Health Center Program. In light of this increased scrutiny, HRSA is likely to reform its oversight process and impose stricter monitoring measures on Health Center Program grantees. In enacting such reforms, it is possible that HRSA also may examine and increase monitoring of federally qualified health center (FQHC) look-alike entities under its purview, which do not receive grant funds but are required to meet Health Center Program requirements.

8. 19 Key Program Requirements:Making the Grade HRSA provides project officers with a list of key factors and questions related to the 19 program requirements to consider when making their assessment of compliance.

9. # 1 Needs Assessment FQHC demonstrates and documents the needs of its target population, updating its service area, when appropriate Does the grantee have written needs assessment? Does the grantee have a clearly defined service area?

10. #1 Needs Assessment Is the needs assessment comprehensive in terms of encompassing the entire service area? Should it be modified/expanded? When was last needs assessment completed/updated? Has grantee updated service area based on recent data (annual patient origin data)? If not, is it recommended? Have updates been reviewed and approved by Board? What priority needs were identified? What steps were taken to address priority needs? Does defined service area take into account geographic, demographic, or other relevant factors? Are there any concerns or issues around service area overlap?

11. 19: #2 Required and Additional Services FQHC provides all required primary, preventive enabling health services and additional health services, either directly or through established written arrangements and referrals NOTE: FQHC requesting funding to serve homeless must provide substance abuse among their required services

12. # #2 Required and Additional Services Does the center provide all required health center services? Is translation type appropriate for size/needs of grantee and are all documents in appropriate languages? Are the outside providers agreements documented with how service will be documented, how grantee will pay and bill for service, and how grantee’s policies and procedures include applicability of a sliding fee discount schedule?

13. #3 Staffing FQHC maintains a core staff to carry out all required services. Staff is licensed, credentialed, and privileged as appropriate.

14. #3 Staffing Is the core staff appropriate for serving the patient population in terms of size and composition? Are all providers appropriately credentialed to perform activities/procedures detailed in approved scope of project? Are credentialing and privileging policies adequate so as to assure meet requirements?

15. #3 Staffing Budget v. Actual staffing levels Personnel Policies Personnel Files Job and Position Descriptions Performance Evaluations Clinical Staff Provider Credentialing and Privileging Employment Contracts Standard orientation Standard format for agendas and minutes of staff meetings Employee Satisfaction Surveys

16. #4 Hours of Operation FQHC provides services at times and locations that assure accessibility and meet the needs of population to be served • Are the times services provided appropriate to ensure access for population to be served? • Are locations services provided accessible to population to be served?

17. #4 Accessible Hours of Operation Additional times could be open to increase access? Are hours posted in appropriate languages? Is signage clear and appropriately placed? Is size of facility adequate for size of population?

18. #5 After Hours Coverage FQHC provides professional coverage during hours when center is closed Requirements: Is professional coverage for medical emergencies available to patients after center’s closed through clearly-defined arrangements?

19. #5 After Hours Coverage What arrangements available for after hours coverage? Do all patients receive explanation for emergency care after hours? Does phone system provide emergency information? In appropriate language?

20. After Hours Coverage • At a minimum, the grantee should ensure telephone access to a clinician who can exercise professional judgment in assessing a patient’s need for emergency medical care and who can refer patients to an appropriate location for such care, including emergency rooms, when warranted. • Grantee should have an established mechanism for patients needing care to be seen after hours in an appropriate location and ensure that health center clinicians conduct timely follow up with patients seen after hours.

21. #6 Hospital Admitting Privileges and Continuum of Care FQHC physicians have admitting privileges at referral hospitals; if not possible, FQHC must firmly establish arrangements for hospitalization, discharge planning, and patient tracking. • Do health center physicians admit and follow hospitalized patients? • If not, is there a formal, written arrangements outlining arrangements for hospitalization, discharge planning and patient tracking? How is continuum of care ensured?

22. #7 Sliding Fee Discounts FQHC has a system in place to determine eligibility for patient discounts adjusted on the basis of the patient’s ability to pay. NOTE: No discount to patients with incomes over 200% of poverty guidelines. Full discount to those at or below 100%, and sliding scale to those between 100-200%.

23. #7 Sliding Fee Discounts Are all patients provides service regardless of ability to pay? Does center have established sliding fee discount schedule? Approved board policies? Based on most recent federal poverty guideline? Are there signs for communicating availability of sliding fee discount for low income patients? Does schedule of fees cover cost of all services?

24. Sliding Fee Discounts • Grantee should have a fee schedule that provides varying levels of discounts on charges to patients with incomes between 101 and 200 percent of the federal poverty level. • No fee or only a nominal fee that would not be a major barrier to care should be charged to patients with incomes at or below the federal poverty level. • No discount should be provided to patients with incomes above 200 percent of the federal poverty level. • Fee schedule must be based on the most recent federal poverty level guidelines.

25. #8 Quality Improvement Plan FQHC has an ongoing quality improvement or quality assurance program that includes clinical services and management and that maintains the confidentiality of patient records.

26. #8 Quality Improvement Plan QI/QA Program must : • Include clinical services and management • Maintain confidentiality of patient records • Include clinical director focusing on QI/QA and high quality patient care • Include Periodic assessment of service utilization and quality of services by licensed health professionals under supervision of physician

27. #8 Quality Improvement Plan Was QI program reviewed and approved by Board? When? Is health center accredited by national organization? Is center participating in HRSA Patient-Centered Medical/Health Home Initiative? Are roles/responsibilities of the board, Management staff and clinical director clearly defined in QI plan? Does QI plan address all operations areas of center for clinical, environmental, management, financial issues and patient experience? Does center have appropriate insurance coverage in place (like FTCA)? For general liability, D/O, malpractice, property, etc? How is risk management tracked? How are medical records supervised and maintained? Are QI audit reports provided to Board and others When deficiencies are identified, are there follow-up reports to Board and action plans implemented?

28. #9 Key Management Staff FQHC maintained fully staffed health center management team for the size and needs of center HRSA requires review on all final candidates for CEO/Exec Dir/Project Director positions.

29. #9 Key Management Staff What is composition of management team? Are key management staff directly employed by center? If not, what arrangements are in place? Are key strategic planning goals tied to performance evaluations for senior mgmt staff? What is CEO’s professional background? Does clinical Director advise CEO and Board on clinical issues and have lead responsibility for hiring/firing clinical staff? Are methods in place to ensure competency in key positions? What systems in place to manage multiple sites?

30. #10 Contractual Agreements FQHC exercises appropriate oversight and authority over all contracted services, including assuring that any sub-recipient meets health care program requirements Question: Do any of the center contracts have the potential to threaten the center’s integrity or limit its autonomy, or compromise its compliance with federal program requirements?

31. #10 Contractual Agreements Do the center’s contractual arrangements: • Contain provisions about activity to be performed, time schedules, policies, and maximum amount of money center may become liable? • Require contractor to maintain appropriate systems and records and access? • Comply with federal procurement standards? • Include contract is subject to termination in event of breach? Does Board review/approve all new affiliations to maintain oversight? Is center able to address any specific legal or fiscal concerns related to contracts with their own legal counsel/auditor?

32. #11 Collaborative Relationships FQHC makes effort to establish and maintain collaborative relationships with other health care providers in the service area Secure letter of support from existing FQHC in the service area or explain why letter cannot be obtained

33. #11 Improving Collaborative Relationships How could center strengthen working relationships with other nearby health centers, public health depts, private providers, rural health clinics, hospitals, other stakeholders? If center unable to secure letter of support from existing FQHC, what steps could take to improve relationship? Does center have any collaborative relationships that support ER preparedness and management plan/activities?

34. #12 Financial and Control Policies FQHC maintains accounting and internal control systems for the size and complexity of the organization reflecting GAAP and separated functions to size to safeguard assets and maintain financial stability Conduct annual independent audit including submission of corrective action plan with findings, questioned costs, reportable conditions, and material weaknesses cited in the Audit Report

35. #12 Improving Financial and Control Policies Is there a monthly cash budget for center with monthly projections for at least 12 months? Are monthly financial statements prepared for review by finance committee and Board? Do last 3 monthly financial statements have adequate cash on hand, reasonable levels of AR and AP Are expenses appropriately allocated? Does center have written purchasing and cash disbursement policies? Are accounting procedures adequate to result in financial results from operations? Does center know expected breakeven point for operations in terms of patient volume and mix to ensure viable fiscal operations? More…..

36. #13 Billing and Collections FQHC has systems in place to maximize collections and reimbursement for its costs in providing health services, including written billing, credit and collection polices and procedures

37. #13 Billing and Collection • Center should maintain documented billing and collections policies and procedures. • Center must have the ability to bill Medicaid and Medicare. • Center must make reasonable efforts to collect reimbursements from patients.

38. #13 Billing and Collection Improvement Encounter Forms Medicare/Medicaid Other Third-Party Billing Self-Pay Accounts Receivable

39. #14 Budget FQHC has developed a budget that reflects the costs of operations, expenses, and revenues (including federal grant) necessary to accomplish the service delivery plan, including number of patients to be served

40. #14 Improving Budget Does center have capital plan? Approved by Board? If so, when? Is annual budget reasonable in terms of accomplishing service delivery plan, in particular the project number of patients to be served?

41. #15 Program Data Reporting Systems FQHC has systems which accurately collect and organize data for program reporting and which support management decision making Does center have systems and capacity for collecting and organizing data required for UDS and FFR reporting and Clinical and Financial Performance Measure Forms? Is information used to inform and support management decisions? Does center have long term strategic plan?

42. #15 Program Data Reporting Systems Officers are trained to pick 1-2 Required Clinical Measures to focus on and 1-2 Financial Measures. Is there significant room for improvement? Is there a negative historical trend for performance measure suggesting intervention necessary? Is grantee committed to developing an action plan to improve performance on the selected measure? Current needs of staff, familiarity and accuracy of UDS reporting and FFR reporting Future Needs – assessing HIT needs, EHR standards and meaningful use standards

43. #16 Scope of Project FQHC maintains its funded scope of project including any increases based on recent grant awards Any significant decreases in # of overall patients served, special populations served, providers or services available, sites? Has center received any other grant awards in last 5 years and were they successful?

44. #16 Scope of Project Based on purpose of grant award received, are there market conditions not reflected in application that may impede goals, such as: • Growth in # of patients • Growth in # of patient visits • Addition of new services • Addition of new providers • Addition of new sites • Other expansions/ improvements Current Capacity Planned Expansions of service area/sites Other Lines of Service / outside of scope

45. #17 Board Authority FQHC Board maintains authority by: • holding monthly meetings and maintain minutes; • approving grant application and budget; • Selecting and evaluating performance of CEO; • Selecting services and hours of operation • Measuring and evaluating annual and long term goals; developing long-range plans; ongoing review of bylaws, and such • Establishing general policies of FQHC

46. #17 Board Authority Improvement Monthly board packets Is there standard format for agendas and minutes for Board meetings? Do bylaws specify expectations regarding meeting attendance and policies for removal of inactive members? When were bylaws last reviewed and approved? Corporate Compliance: approved plan? Committee? Compliance officer? Which senior management staff attends meetings? Does Board have a self-evaluation process?

47. #18 Board Composition FQHC Board must meet statutory requirements: • Patient-centered majority (51% of board members are patients, receiving services at health center)who are reasonably representative of patient community in race, ethnicity and sex • Composed of 9-25 members, which comply with bylaws and size appropriate for organization and diversity of community served • Remaining board members must be representative of community and service area with at least one member with expertise in community affairs, local govt, finance, legal affairs, trade unions, business, social services or health • No more than 50% of members may derive more than 10% of annual income from healthcare industry

48. #18 Improving Board Composition Does center have a board recruitment and retention plan, orientation program for new board members and plans for ongoing training? Does overall expertise among members reflect scope in terms of services, needs, target population, and service area? Has Board composition taken into account key demographic factors such as socioeconomic status and age?

49. #19 Conflict of Interest Policy FQHC bylaws or written corporate board approved policy include provisions that prohibit conflict of interest by board members, employees, consultants, vendors State: No board member shall be employee of FQHC or immediate family member of employee State: CEO may only serve as non-voting ex-officio member of board

50. #19 Conflict of Interest Policy • Do the grantee’s bylaws or other policy documents include a conflict-of-interest provision? • Address Disclosure of relationships that create actual or potential conflict of interests, including nepotism; • Address Extent to which board members can participate in decisions where the member has a personal or financial interest; • Address Using board members to provide services to the health center; • Address Board member expense reimbursement policies; • Address Acceptance of gifts and gratuity; • Address Personal political activities of members; and • Address consequences for violating the conflict-of-interest policy