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Compliatric Deep Dive Into HRSA Site Visit Protocol Updates


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Compliatric Deep Dive Into HRSA Site Visit Protocol Updates

  1. 1. Deep Dive- Updates to the HRSA Site Visit Protocol COMPLIATRIC WEBINAR SERIES Presented by : Jennifer Genua-McDaniel
  2. 2.  This presentation is not endorsed by Management Strategists Consulting Group (MSCG)  This presentation is not endorsed by Health Resources Services Administration (HRSA) or Bureau of Primary Health Care (BPHC)  Not employed by MSCG or BPHC  Independent Consultant who is contracted to do Operational Site Visits (OSV)s and Technical Assistance (TA)  Not intended to provide legal advice  Please refer to your HRSA Project Officer (PO) for specific questions
  3. 3.  Updates to the SVP ◦ What has updated ◦ What has NOT updated  Review requirements with updates ◦ Specific elements that have been clarified  Maintaining continuous compliance CHANGE TO HRSA COMPLIANCE MANUAL NO
  4. 4.  Thanks to feedback: ◦ Revisions to documents requested, methodologies, questions asked and improved efficiencies ◦ Clarifications of overlapping sections ◦ “Related considerations” added to the SVP  HRSA Compliance Manual and HRSA SVP better aligned
  5. 5.  Consolidated Documents ◦ Now one list  No “documents prior” and “documents at the start”
  6. 6.  Performance Analysis ◦ Removed from the process February 2021 ◦ Streamlined the site visit process to focus on compliance ◦ Request technical assistance through HRSA PO  Health Centers WITH Sub-Recipients ◦ Methodology to assess compliance expanded to specific requirements (board authority/composition and sliding fee discount program)  Eligibility for Look-Alike ID Applicants ◦ Aligned the criteria contained in the Look-Alike applications
  7. 7. NOT UPDATED CLARIFIED/UPDATED  HRSA Compliance Manual  How Virtual OSVs are completed  Following Program Requirements: ◦ Quality Improvement/Assurance ◦ Budget ◦ Program Monitoring/Data Reporting Systems ◦ Board Authority ◦ Promising Practices  Consolidated Checklist  Performance Analysis no longer completed  Program Requirements ◦ Methodologies ◦ Questions to assess compliance ◦ Clarification on assessing compliance
  8. 8.  Review the Chapter and specific element that is clarified ◦ Clarifications can be minor ◦ Clarifications provide additional information to assess compliance
  9. 9.  Element A  Comparison of Form 5B zip code and most recent UDS zip codes ◦ Where are your patients coming from? ◦ Does your Form 5B reflect updated zip codes?
  10. 10. Clarification for reviewers on methodologies on samples Updated questions in Element A (Providing and Documenting Services within Scope of Project) Added a question on consistency of Form 5A (Scope of Services) and whether any Changes in Scope (CIS) were submitted
  11. 11.  Updated questions in Element A (Providing and Documenting Services within Scope of Project) ◦ Column II
  12. 12.  Updated questions in Element A (Providing and Documenting Services within Scope of Project) ◦ Column III
  13. 13.  Clarification of Element C (Procedures for Review of Credentials) and Element D (Procedures for Review of Privileges) to specify who constitute “clinical staff”
  14. 14.  Element D (Procedures for Review of Privileges) requires an explanation of HOW the health center verifies fitness for duty ◦ Health Center makes the decision on how to verify fitness for duty ◦ Needs to be documented
  15. 15.  Element F (Credentialing and Privileging of Contracted or Referral Providers) provides examples of how a health center might assess contracts and referral arrangements for compliance with credentialing and privileging requirements.
  16. 16.  Element C (Accurate Documentation of Sites within Scope) clarified the question on whether Form 5B is correct
  17. 17.  Clarifications on samples provided through footnotes and documentation of after hour follow up
  18. 18.  Clarification of samples of hospital admissions  Documentation for hospital samples ◦ Need to document the health center’s entire hospitalization tracking process, from admission and follow-up through closure.
  19. 19.  Clarification for reviewers on assessing compliance  Clarification on how to determine that the nominal fee is nominal from the perspective of the patient
  20. 20.  Element I (Sliding Fee for Column II Services) & Element J (Sliding Fee for Column III Services) ◦ Clarification: for any service(s) delivered via Columns II or III, HRSA expects health centers to provide any other supporting documentation not included in the written contracts/agreements, showing how health centers ensure application of the sliding fee discount program for these services.
  21. 21.  Element E (HRSA Approval for Project Director/CEO Changes) ◦ Updated the methodology when there is a new Project Director/CEO since the start of the current project
  22. 22.  Clarification on which reviewer assesses compliance ◦ If Sub-recipient, then Admin/Governance Reviewer  Sub-Recipient Clarification (Elements G-J) ◦ Reviewers will focus on the health center’s monitoring of subrecipient’s compliance with board authority, board composition, and sliding fee discount program requirements
  23. 23.  Clarification procurement and contract samples ◦ What is required in contracts is the same ◦ Supporting documentation for procurement process is the same  Rationale, Selection, Contractor selection/rejection, basis for price
  24. 24.  Element F (Required Contract Provisions) ◦ Clarification of contract samples ◦ What is required in the contract is the same  Specific activities/services performed  Monitoring performance  Data reporting expectations and intervals  Provisions for record retention, access, audit and property management
  25. 25.  Administrative/Governance Reviews  Clarification of Contract Samples
  26. 26.  Element D (Adherence to Standards of Conduct) ◦ Updated methodology to assess compliance
  27. 27.  Updated methodology so the health center can provide additional details of partnerships and collaborations
  28. 28.  Element C (Drawdown, Disbursement and Expenditure Procedures) ◦ Added a footnote for information on annual appropriations that limit the use of HRSA awards
  29. 29.  Element F (Timely and Accurate Third-Party Billing) ◦ Clarified billing samples ◦ All other elements the same:  Submit claims within 14 business days from the date of service  Correct and resubmit claims that have been rejected due to accuracy
  30. 30.  Clarification: ◦ Provide Form 6A (Board Characteristics)  Make sure it’s reflective of current practice  Element A (Board Member Selection and Removal Process) ◦ How bylaws/health center documentation demonstrates board member selection or removal.
  31. 31.  Element C (Current Board Composition) ◦ Clarifying information to address board evaluation of patient representation using UDS and descriptions of board member connections to the community.
  32. 32.  Not factored into compliance during the OSV  Clarification of risk management documentation required and an additional question on claims related documentation
  33. 33. HRSA Compliance Manual has not changed Review the updated Protocol Talk with your HRSA Project Officer with any clarifying questions Review HRSA Resources • • •
  34. 34.  Jennifer Genua-McDaniel, BA (Hons), CHCEF ◦ Genua Consulting, LLC ◦