The presentation discusses compliance challenges and opportunities in the healthcare industry amidst evolving payment and delivery models. It emphasizes the importance of program integrity principles, quality data analytics, and the role of human resources in fostering a compliance culture. Additionally, it highlights new regulatory flexibilities designed to improve access to care and reduce costs.

1. Presentation prepared for
AHLA Annual Meeting
June 26-29, 2017
Ready or Not?
Compliance in a World of New Models

2. Page 1
OBJECTIVES
• Review core program integrity principles
• Consider compliance risks presented by new models of
payment and delivery
• Examine the role of quality and data analytics in improving
compliance under new models of payment and delivery
• Explore new regulatory flexibility for increasing access to care
and reducing costs
• Discuss how human resources can drive a compliance culture
• Educate start-ups and non-traditional players on program
integrity principles

3. Core Program Integrity Principles

4. Page 3
Road
100 m
Menu
PREVENT
• Knowing with whom you do
business
• Are they trustworthy?
DETECT
• Having tools to detect problems
• Creating a Culture of Compliance
so that people are empowered to
report problems
ENFORCE
• Having tools to take actions to fix
problems
• Training and new controls
• Self-reporting
Finding True North:
Essential for Accurate Navigation

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Source: https://oig.hhs.gov/compliance/101/files/HCCA-OIG-Resource-Guide.pdf

6. Compliance Considerations for New
Models of Payment and Delivery

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Examples of New Models of Payment and Delivery
 New models of payment
 Quality-based adjustments to fee-for-service payments
 Shared savings
 Episode-based payments
 Population-based payments
 Capitation
 Impact on delivery of care in many settings
 Hospital
 Physician
 Home health
 Dialysis
 Post-acute
 Behavioral health
 Ancillary services

8. Page 7
Alternative Payment Models (APMs)
FEE-FOR-SERVICE
(FFS) PAYMENTS
POPULATION-BASED
APMs
ADJUSTED FFS
PAYMENTS
APMs INCORPORATING
FFS PAYMENTS
$
$
Bank
A Pay for reporting
B Pay for
performance
C Pay/penalty
for performance
A Total cost of care
shared savings
B Total cost of care
shared risk
C Retrospective
bundled payment
D Prospective
bundled payment
A Condition-specific
population-based
payments
B Primary care
population-based
payments
C Comprehensive
population-based
payments
A Traditional FFS
B Infrastructure
incentives
C Care management
payments

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Compliance Considerations for
New Models of Payment and Delivery
OIG work plans in this area
Changed incentives under new models
Program integrity risk areas (e.g., stinting
on care)

10. Role of Quality and Data Analytics in
Compliance

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Data Issues & Quality Outcomes
 New models rely significantly on data, EHRs, and
technology
 Complete, Accurate, Timely, Secure (CATS)
 How data is used for program integrity by the government
 e.g., Merit-Based Incentive Payment System (MIPS)
 Quality driving compliance
 Insight into what’s actually happening in your organization
 The rise of Patient Safety Organizations (PSOs)

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Public Reporting

13. New Regulatory Flexibility for Increasing
Access to Care and Reducing Costs

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New OIG Regulations
 81 Fed. Reg. 88,368 (Dec. 7, 2016)
 Anti-Kickback Safe Harbors
 Exceptions to the Civil Monetary Penalty (CMP) Rules on
Beneficiary Inducement
 Goals
 Improving access to quality care
 Addressing needs of providers and patients in rural areas
 Considering underserved communities

15. Human Resources Role
in Creating a Culture of Compliance

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HR as an Ally
 HR at the core of organizational culture
 Hiring the right talent
 Education and training
 Knowing with whom you do business
 Active prevention & detection
 Having tools to detect problems
 Compliance audits
 Hotline
 Sharing resources & best practices
 Communication & collaboration

17. Compliance in the Healthcare Industry
for Start-Ups & Non-Traditional Players

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Compliance Considerations
for Start-Ups & Non-Traditional Players
 Who are the new players?
 Technology, telehealth, data-aggregators
 e.g., eClinicalWorks’ False Claims Act case
 What is different about compliance in the healthcare
industry?
 Medicare and Medicaid Fraud and Abuse Laws
 Privacy and Security Laws (specific to healthcare data)
 FDA Laws
 Licensing laws (e.g., DME licensing or registration)

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Questions

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Contact Information
Kristen M. Lilly,
MHA, CHC, CPHQ, RHIA
PYA
klilly@pyapc.com
Fatema Zanzi, Esq.
Drinker Biddle & Reath LLP
Fatema.Zanzi@dbr.com
Vicki L. Robinson, Esq.
Office of Inspector General
U.S. Department of Health
and Human Services
Vicki.Robinson@oig.hhs.gov

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Disclaimer
This presentation contains slides that have been combined
for purposes of presentation continuity. The speakers do
not necessarily endorse the content of each other’s slides.
Moreover, the views expressed in this presentation belong
to the speakers and do not necessarily represent the views
of their organizations or other organizations.