A CIA is a tool used by the OIG to address violations at healthcare organizations through policies and procedures designed to enforce compliance with regulations. A CIA is usually coupled with a civil settlement between the provider and the government to avoid exclusion from federal health programs. In this presentation, we will discuss how to use recent CIAs to derive best practices that can benefit your organization. We will cover: -Common guidelines found in multiple CIAs -Best practices from CIAs for specific types of healthcare entities -Easy ways to improve your physician contracting compliance -And more!

1. 1
UNCOVERING BEST PRACTICES FROM
CORPORATE INTEGRITY AGREEMENTS
FEBRUARY 2019

2. Nice to meet you
Allison Pullins
• Leadership team at MD Ranger since
2012; 12 years of industry experience
• 200+ hospital/health system clients
• Hosted 60+ educational webinars
• Published author, including Becker’s
Healthcare
• Volunteer and fundraiser for The
Marfan Foundation
• Loves: black coffee, Fraiser re-runs,
pre-dawn exercise
• Pet peeves: dirty refrigerators,
whining, temperamental thermostats
2

3. 3
Key takeaway: let’s learn from CIAs!
• All physician contracting programs
should have policies and
procedures—but where to start?
• A great way to create compliance
processes is to review
requirements outlined in recent
CIAs
• BE PROACTIVE—CIA’s are meant to
help organizations avoid problems
and quickly identify issues that
might arise

4. 4
Today’s agenda
• CIAs “101”
• Uncovering best practices in
existing CIA’s
• Applying lessons to your
physician contracting program

5. 5
CIA 101

6. • Used by OIG to address violations at healthcare
organizations. They are made up of policies and
procedures designed to enforce compliance with
regulations.
• Usually paired with a settlement between the
provider and the government.
• CIAs have been issued for all types of healthcare
entities.
6
What are corporate integrity agreements?

7. 7
Who enforces CIA’s?
• Monitors are assigned to
violating organizations
• Collaborative role that
works with the Compliance
Officer
• Goal: identify problems
before they become
violations

8. 8
What happens if you violate a CIA?
• Monetary penalties for
the failure to comply
• Provider exclusion
from participation in
federal health care
programs

9. 9
UNCOVERING
BEST PRACTICES
IN CIAS

10. 1. Hire a compliance officer/appoint a
compliance committee
2. Develop written standards and policies
3. Implement a comprehensive employee
training program
4. Retain an independent review
organization to conduct annual reviews
5. Establish a confidential disclosure
program
6. Restrict employment of ineligible
persons
7. Report overpayments, reportable
events, and ongoing investigations/legal
proceedings
8. Provide an implementation report and
annual reports to OIG on the status of
the entity's compliance activities
10
Typical CIA Requirements

11. 1. Hire a compliance officer/appoint a
compliance committee
2. Develop written standards and policies
3. Implement a comprehensive employee
training program
4. Retain an independent review
organization to conduct annual reviews
5. Establish a confidential disclosure
program
6. Restrict employment of ineligible
persons
7. Report overpayments, reportable
events, and ongoing investigations/legal
proceedings
8. Provide an implementation report and
annual reports to OIG on the status of
the entity's compliance activities
11
Typical CIA Requirements

12. 12
Compliance Officer and Committee
“Within 90 days after the Effective Date,
KRHS shall appoint a Compliance Officer
and shall maintain a Compliance Officer
for the term of the CIA. The Compliance
Officer shall be an employee and a
member of senior management of KRH,
shall report directly to the Chief Executive
Officer of KRH, and shall not be or be
subordinate to the General Counsel or
Chief Financial Officer or have any
responsibilities that involve acting in any
capacity as legal counsel or supervising
legal counsel functions for KRHS.”
-Kalispell Regional Medical Center, CIA from
September 24, 2018

13. 13
Develop written standards and policies
“Within 90 days after the Effective Date, Halifax shall
implement written Policies and Procedures regarding
the operation of Halifax’s Compliance Program,
including the Compliance Program requirements
outlined in this CIA and Halifax’s compliance with
Federal health care program requirements. At a
minimum, the Policies and Procedures also shall
address:
Anti-Kickback Statute and Stark Law; the
regulations and other guidance documents
related to these statutes; and business or
financial arrangements or contracts that
generate unlawful Federal health care program
business in violation of the Anti-Kickback Statute
or the Stark Law.”
-Halifax Hospital Medical Center, CIA from March 10, 2014

14. 14
Training and education
“Within 120 days after the Effective Date, each Arrangements
Covered Person shall receive at least two hours of
Arrangements Training…
a. Arrangements that potentially implicate the Anti-Kickback
Statute or the Stark Law, as well as the regulations and
other guidance documents related to these statutes;
b. Tuomey’s policies, procedures, and other requirements
relating to Arrangements and Focus Arrangements,
including but not limited to the Focus Arrangements
Tracking System, the internal review and approval process,
and the tracking of remuneration to and from sources of
health care business or referrals required by Section III.D
of the CIA;
c. the personal obligation of each individual involved in the
development, approval, management, or review of
Tuomey’s Arrangements to know the applicable legal
requirements and Tuomey’s Policies and Procedures;
d. the legal sanctions under the Anti-Kickback Statute and
the Stark Law; and
e. examples of violations of the Anti-Kickback Statute and the
Stark Law.
- Tuomey Healthcare System, CIA from
October 2015

15. 15
APPLYING
LESSONS TO
PHYSICIAN
CONTRACTING
PROGRAMS

16. • Prevent
• When incidents happen, swift
response imperative
• Don’t violate Stark or AKS!
• Never pay for referrals
• Do not pay above FMV for services
16
An ounce of prevention…

17. 17
Process and policies are key
• You must create a standard physician
contracting and documentation
process
• It doesn’t have to be fancy
• It doesn’t need to have many
resources
• Consistency is crucial

18. 18
Develop a policy to determine FMV
• Document the FMV process and stick
to a consistent method
• Some organizations primarily use
market data and tap into consultants
for more complex contracts
• This method reduces number of
individual FMV opinions

19. 19
Setting the appropriate payment range
• Best practice organizations use
their ”profile” to determine
where on the market ranges
the vast majority of their
agreements should fall
• Typical thresholds are either at
the median or the 75th
percentile

20. A sample policy, condensed
• The simplest thing to do is use market data as the foundation of your
process.
• Determine what payment ranges fit the profile of your organization
best, and stick to those ranges in most circumstances
• Outline your workflow; it should look something like this:
• Check commercial reasonableness
• Review contract’s scope of services
• Identify benchmarks for the service
• Select your rate or acceptable range
• Negotiate
• Document!

21. 21
Step 1: Test commercial reasonableness
• Check MD Ranger
“Percent Paying”
benchmarks
• Once commercial
reasonableness is
established, document it

22. Step 2: Review the contract’s scope of
services
• Though no two contracts rarely are the same, it’s
important to compare similar positions
• Examine scope to ensure that hours per month are
reasonable; use historical time records and market data
to document
• Pay special attention to positions with burdensome
implementation or extended hours
• Check restricted or in-house status for coverage
agreements since this may increase FMV

23. Step 3: Identify benchmarks for the
service
• Find the most appropriate match for the service
• Compare similar organizations
• Check sample size
• Examine the full market range, and ask:
• What’s the median? What is the 75th percentile?
• Are there reasons for my hospital rates to be higher than the median?
• Are there characteristics of my hospital, the service or the physician that could
impact FMV?

24. 24
Step 4: Select your rate
• Remember your organization’s rules
• Your payment rate doesn’t have to be exactly the 75th
percentile; in fact, we don’t recommend it!

25. 25
Step 5: Negotiate

26. 26
Step 6: Document

27. 27
The leadership imperative
• Most CIA’s mandate that
organizations hire a Chief
Compliance Officer—
emphasizing how important
leadership is
• In addition to the compliance
officer, staff and structure also
matter
• Training/education
• Workflow

28. 28
Assign team roles, delegate
• Who is responsible for
determining and documenting
FMV at your organization?
• Who reviews and approves
supporting documentation?
• Who is the responsible
executive for sign off?
• How often does your board
review contract rates and
compliance?

29. 29
Do you have this? If no…
1. Board-approved policies and procedures help
mitigate risk
2. Apply consistent standards and processes,
documented in a formal“policy”
3. Use a recognized, stable source of market
benchmarks
4. Standardize documentation
5. Maintain contemporaneous inventory of contracts –
and knowledge of how they compare

30. 30
ABOUT
MD RANGER

31. 31
300+ Physician Benchmarks
• Call coverage rates
• Medical direction payments
• Administrative and leadership
• Hospital-based service stipends
• Diagnostic testing, etc.
• Clinic & hourly rates
• Telemedicine rates
Online Platform
• Benchmark lookups
• Contract proposal tools
• Contract reports by facility and
service
• Total facility costs + benchmarks
Research and Support
• Resources for education and
training
• On-call experts to help
subscribers use benchmarks
and tools
Compliance Documentation
• Contract-specific FMV
documentation reports
• Reports to assist with real-time
monitoring and annual reviews
Our platform

32. 32
Standardize
processes
and rates
Document
FMV
Access 300+
payment
benchmarks
Review and
monitor
contracts
Have data-
driven
physician
negotiations
Mitigate
compliance
risks
The foundation of your contracting process

33. 33
Our database

34. 34
• Call Coverage (55+)
• Medical direction (85+)
• Hospital-based services (20+)
• Administrative (12+)
• Medical Staff Leadership
• Diagnostic/other services
e.g. ROP, autopsy, dialysis
• Hospital-based stipends
• Clinics, professional services
• Telemedicine
• Residency/teaching/GME
• Uncompensated care
• Meeting attendance, peer review,
IT/EHR and quality initiatives
• 13 Pediatric services, with more
emerging each year
Hospital-characteristics drill
down for ADC, bed size, trauma
status, urban/rural, stroke
centers, and more.
Our benchmarks
Used in such diverse settings as
academic medical centers,
integrated delivery systems, and
critical access facilities
nationwide

35. • Unique scope of benchmarks
• Hospital characteristics
• Providers vs. facilities
• Thorough data audits
• Physician contract experts
on-call to review/advise on
challenging contracts
35
Standing out from the crowd

36. 36
 Are you resource-constrained?
 Do you feel like your organization has
risky agreements?
Reach out: apullins@mdranger.com or 650-
692-8873
Need help?