Effective Date: July 21, 2015
CCPM’s Compliance Hotline: 877-874-8416
This document sets forth the elements of the Compliance Plan for the Community Care Partnership of Maine, LLC (“CCPM”), an LLC formed to (i) participate in cost savings and other arrangements with government programs, commercial insurers and other payers; (ii) develop a network of health care providers for the delivery of health care services according to applicable rules, regulations and contractual obligations for the purpose of improving the quality and efficiency of health care and the patient care experience; (iii) promote evidence-based medicine, patient engagement, reporting on quality and cost, and care coordination and distribution of shared savings, and (iv) engage in other similar or related activities. This Compliance Plan incorporates the regulations set forth at 42 CFR Part 425 related to the formation and operation of accountable care organizations, and is created to ensure CCPM abides by applicable federal, state and local laws, rules, and regulations in its formation and operation.
In the conduct of the Company’s business, CCPM and its Members shall comply with all applicable laws, including, but not limited to: (a) federal criminal law; (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); (e) the physician self-referral law (42 U.S.C. 1395nn); and (f) federal and state antitrust laws (15 U.S.C. 1 et seq. and 10 M.R.S.A. §§ 1101-1102-A and 5 M.R.S.A. § 207, respectively). This Compliance Plan creates a structure whereby the organization sets high ethical standards, consistently trains its workforce in those standards, audits and monitors for compliance with law and established standards, provides way for members and their employees/agents to report possible violations of law or this Plan, investigates reported non- compliance, and remedies noncompliance.
In addition to adherence to the Special Rules of Conduct and other applicable laws, CCPM members have committed to a “Shared Statement of Shared Values” (“Values”), attached hereto and incorporated by reference into this Plan. The Values form the ethical foundation for the work CCPM members do together, which is aimed at enhancing community health by providing access to high quality healthcare for all patients, regardless of their ability to pay.
CCPM is committed to compliance with applicable federal, state and local laws, and regulations, including, without limitation, those governing publicly funded health care programs, federally qualified health centers, hospitals, and accountable care organizations (“ACO”); the ethical standards set forth in its Statement of Shared Values and Code of Conduct; the terms and conditions of any contractual agreement with the Centers for Medicare and Medicaid Services (“CMS”), the State of Maine, or any other public or private payer. To that end, CCPM maintains an effective compliance program modeled on the guidelines established by the Office of the Inspector General for private physician practices, hospitals, and Medicare Advantage Plans, the regulations governing ACOs at 42 CFR Part 425, as well as guidance promulgated by anti-trust regulators and CMS related to the formation and operation of ACOs. This Compliance Plan outlines the organization of the program, including requirements for staff training, audit protocols, and reporting and investigation mechanisms. The Plan is designed to promote full compliance with applicable law, and to ensure that any deviations from the law are promptly detected, investigated, and corrected.
- CCPM Governing Structure. CCPM is a limited liability company formed under the laws of Maine, consisting as of July 21, 2015 of ten member organizations. CCPM is governed by a Board of Managers as set forth in the Second Amended and Restated Operating Agreement, effective July 21, 2015. Each member has one has appointed one Manager to the Board of Managers. The Board of Managers also includes one Medicare beneficiary, as required by federal regulations, that is served by the ACO, does not have a conflict of interest with the ACO, and does not have an immediate family member who has a conflict of interest with the ACO. Members may be added to CCPM by a super- majority vote of the Board of Managers, as outlined in the Operating Agreement.
- Compliance Officer and Counsel to the CCPM. The Compliance Officer for CCPM shall be Lori Dwyer, Esq., who also serves as the Compliance Officer for member organization Penobscot Community Health Care (“PCHC”). Counsel to CCPM shall be the law firm Verrill Dana in Portland, Maine.
- Compliance Officer Responsibilities: The Compliance Officer shall report directly to the Board of Managers and the Chief Executive Officer of CCPM and the CCPM Board of Managers. The Compliance Officer shall be responsible for
- Overseeing and monitoring CCPM’s compliance activities, including the development and implementation of a Code of Conduct;
- Ensuring the effectiveness of the compliance program through auditing and monitoring;
- Ensuring alignment of the compliance program with applicable state and federal laws;
- Reporting periodically to the CCPM leadership team and the Board of Managers on compliance matters and advising CCPM on appropriate compliance policies and procedures, reporting probable violations of law, repaying overpayments to the extent CCPM receives any payment for services, and other applicable compliance matters;
- Reviewing and revising elements of the compliance Plan to addresschanges in regulatory requirements;
- Serving as a knowledgeable resource to organizational and operationalmatters relating to compliance;
- Developing and implementing a compliance education program for CCPM members;
- Receiving and investigating reports of potential non-compliance or otherconduct that may violate applicable laws, regulations, policies or ethics; and
- Developing policies that encourage the reporting of non-compliance orsuspected fraud, waste and abuse and ensuring that those who do report may do so without fear of retaliation.
- Code of Conduct: The CCPM Code of Conduct and Statement of Shared Values (collectively, “Code of Conduct”) are essential components of the compliance plan. Taken together, they establish the general ethical and compliance expectations for CCPM, its provider/suppliers, employees, contractors, and others who perform functions or services to CCPM. The Code of Conduct is made available to all CCPM members and staff, is the subject of compliance training, and is available through electronic means or upon request.
- Policies and Procedures.
- CCPM develops and maintains policies and procedures to ensure that the ACO business and operations are conducted in accordance with this plan, the Code of Conduct, and statutory and regulatory requirements. These policies will be made available electronically to all CCPM participants.
- To the extent permitted by law, each member extends its own existing compliance policies to include activities undertaken for the ACO, and, in addition, shall update its existing Compliance Plan to reflect the requirements of this Plan. In addition, CCPM shall adopt policies and procedures as follows:
- Internal audit/monitoring policy to ensure compliance with this Plan and Code of Conduct;
- Polices addressing compliance with the fraud & abuse policy, including prohibitions found in federal and state criminal law, such as anti-kickback laws, stark laws, false claims act, referrals among ACO members, gainsharing CMP, and prohibitions on patient inducements
- Non-discrimination and equal employment opportunity
- Prohibition on unlawful Referrals
- Confidentiality of protected health information
- Prescribing controlled substances
- Record retention and destruction (General 10-year retention period for ACO documents)
- Information Security/HIPAA Security Rule Compliance
- Notification of breach of protected health information
- Reporting, investigating and correcting violations of the law or the Code of Conduct
- Training and education
- When an organization becomes a member of CCPM, it shall provide copies of its written compliance program and policies to the CCPM Compliance Officer and shall work with the Compliance Officer to ensure its policies sufficiently address legal and regulatory requirements. CCPM members shall work collaboratively with the CCPM Compliance Officer to foster adherence to both the individual member’s and the ACO’s compliance plan.
- Education: The Compliance Officer shall provide annual training and make available educational resources and training modules for ACO members to ensure they are knowledgeable about the statutes and regulations applicable to the ACO and to individual healthcare provider entities. ACO participants and the ACO Board of Managers shall be educated, at a minimum, in the following areas:
- Physician self-referral, anti-kickback statutes and civil monetary penalties, including the application of CMS final waivers in connection with ACO start-up and ongoing operations (42 C.F.R. Chapter V), other fraud & abuse laws, federal and state criminal law related specifically to healthcare fraud, referrals among ACO members, gainsharing CMP, and prohibitions on patient inducements
- Anti-trust law and its application to ACOs
- ACO beneficiary rights
- ACO Marketing requirements
- Reporting and investigating suspected violations and complaints
- Conflict of interest requirements
- Data sharing, other information security requirements, Patient Confidentiality
- Record retention
Other education may be provided as necessary to address evolving compliance risks, including but not limited to items addressed in OIG reports or identified during internal or external audits of CCPM or any of its participant organization. The Compliance Officer shall keep a record of education and training provided to CCPM members and vendors, and shall maintain the contents of each training.
- Conflict of Interest: CCPM has a conflict of interest policy that applies to members of the governing body and which requires annual and ongoing disclosures of relevant financial interests, a process for determining whether a conflict of interest exists, a process for addressing any conflicts that arise, and remedial steps that will be taken in the event members of the governing body fail to comply with the policy.
- Fraud, Waste, Abuse and False Claims. Participating CCPM organizations have policies and processes in place to audit and monitor compliance with coding, documentation and billing requirements, to detect and correct errors, inaccuracies and improper payments or claims.
- Reports to Law Enforcement. CCPM shall report probable violations of law to the appropriate law enforcement agency.
- Governmental Inquiries, Audits or Investigations: CCPM commits to timely and full cooperation with governmental inquiries, audits and investigations, and the adherence to standards and protocols that involve the CCPM’s legal counsel, the Compliance Officer, as well as the Compliance Officers of CCPM’s member organizations.
- The Role of CCPM and CCPM Member organizations in the Compliance Program; Reporting Procedures and Commitment to AccountabilityAll individuals affiliated with the ACO are expected to comply with CCPM’s Compliance Plan and Code of Conduct, and its policies and procedures and are required to promptly report concerns about possible violation of the Code of Conduct, PFP’s compliance policies and procedures, or other applicable laws, regulations or policies. Individual affiliated with the ACO also commit to holding themselves, their employees and other members of their workforce accountable for violations of the CCPM Compliance Plan, Code of Conduct, policies or procedures. Reports may be made as follows:
- Standard Channels: Through standard channels at the CCPM member organization, beginning with the immediate or next level supervisor.
- To the CCPM Compliance Officer: at 207‑404‑8074.
- Anonymously: by calling the Compliance Hotline telephone number, 1‑877‑874‑8416
Members of the Board of Managers should make compliance reports directly to the Compliance Officer. All reports may be made confidentially. The Compliance Officer shall investigate any reports and maintain confidentiality to the extent possible throughout the investigation. Individuals are expected to cooperate fully in the investigation of any potential non-compliance. CCPM will honor requests for confidentiality to the extent possible, but it must also meet its obligation to investigate possible violations of standards or laws in a timely manner which may involve disclosure of some of the information learned in the report.
Reporting potential non-compliance or violations of the Code of Conduct are essential elements of the job performance of each employee of CCPM, and of the agents/employees of member organizations. CCPM expects strict adherence to this Plan and the Code of Conduct, which includes these reporting requirements.
- Prohibition Against Retaliation. Anyone who reports a compliance concern in good faith is protected by law from retaliation. Any employee or other workforce member of CCPM or any CCPM member who retaliates against another individual for reporting a potential non-compliance or for his or her participation in addressing potential non-compliance issue to CCPM will be subject to discipline or sanction by CCPM. Any CCPM member that retaliates in any way against its own employee or the employee of another CCPM member organization for making a report of non-compliance or participating in a compliance investigation will be sanctioned by CCPM pursuant to the bylaws and as determined by the Compliance Officer in consultation with the Board of Managers. Additionally, any individual who makes any intentionally false accusation regarding a compliance concern is subject to discipline or sanction by CCPM or one of CCPM’s members.
This Compliance Program and Code of Conduct shall be reviewed periodically and updated consistent with the requirements established by the Board of Managers, senior management, Federal and State law and regulations, and applicable accrediting and review organizations.