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CeCN Compliance Program

Community eConsult Network, Inc. Compliance Program

Introduction

  • Scope of Compliance Program
  • Management and Consulting Services
  • Clinical Services
  • Authorized by the Board of Directors
  • Framework
  1. Ensuring Compliance Through Policies and Procedures
    • A. Standards of Conduct/Conflict of Interest
    • B. ConferMED’s Policies and Procedures
      1. Operational Policies and Clinical Policies
      2. Health Information Management (HIPAA) Policies
    • C. Nondiscrimination
    • D. Fraud, Waste and Abuse
    • E. Billing Practices
    • F. Compliance with Managed Care Contracts, Rules and Regulations
    • G. Screening for Excluded Persons
    • H. Record Retention
  2. Designation of Compliance Officer
  3. Education and Training
  4. Communications
  5. Risk Assessment, Internal Monitoring and Auditing
  6. Disciplinary Standards
  7. Corrective Action

Introduction

Statement of Purpose: Community eConsult Network, Inc. (“CeCN”) has implemented its Corporate Compliance Program to mitigate risk; ensure compliance with all applicable Federal and State laws and regulations; deter potential fraud, waste, and abuse; and promote an organizational culture that encourages ethical conduct.

Scope of Compliance Program: This Compliance Program, including all standards, policies, and procedures referenced herein, apply to all operations, programs, and services of CeCN including when it operates as a provider of healthcare services and when it functions as a management services organization for other healthcare providers.

When applicable, this program applies to members of CeCN’s Board of Directors (officers and directors) (the “Board”), employees, agents, students/interns and contractors. This Compliance Program is intended to demonstrate CeCN’s commitment to observing the highest standard of conduct, to promote the integrity of the organization, and summarize its compliance with all applicable state and federal laws.

Management and Consulting Services: CeCN primarily serves as a management services organization for healthcare providers delivering the eConsult and telehealth specialty services described below (“Management Services”). Those healthcare providers pay CeCN a management services fee. CeCN also provides consulting services to healthcare providers, including but not limited to training and professional development (“Consulting Services”), which may or may not require the use of or access to protected health information. The healthcare providers pay CeCN directly for such services.

Clinical Services: A small portion of CeCN’s business involves the provision of certain healthcare services. When CeCN provides healthcare services it focuses on supplementing primary care with specialist consultations. It does this in two ways: (1) asynchronous electronic consultations between a CeCN specialist and a primary care provider (“PCP”) through a secure platform (“eConsult”); and (2) on request of the PCP, a CeCN specialist will conduct a live telehealth session with the patient for consultation purposes. In each instance, CeCN works directly with the PCP/clinic. In most instances, the primary care clinic or a grant pays for CeCN’s services, although CeCN does bill insurance companies for services in some states.

Authorized by the CeCN Board of Directors: To ensure that CeCN’s operations comply with applicable Federal, State, and local laws, the Board, after careful consideration and review, adopted this Compliance Program.

Framework: This program is based on the seven elements of an effective compliance program as outlined by the U.S. Department of Health and Human Services’ Office of Inspector General. These elements include: 1) written policies, procedures and standards of conduct, 2) designation of a compliance officer, 3) effective training and education, 4) effective lines of communication, 5) internal monitoring and auditing, 6) enforce standards through well-publicized disciplinary guidelines, and 7) respond promptly to detected offenses and undertaking corrective action.

In developing this program, CeCN also reviewed the updated guidance for prosecutors when evaluating corporate compliance programs, which was issued by the Criminal Division of the U.S. Department of Justice (DOJ). The DOJ’s September 2024 guidance reiterated three fundamental questions:

  1. Is the corporation’s compliance program well-designed?
  2. Is the program being applied earnestly and in good faith?
  3. Does the corporation’s compliance program work in practice?

Elements

  1. Ensuring Compliance Through Policies and Procedures

    CeCN is a subsidiary of Moses-Weitzman Health System, Inc. (“MWHS”), which is also the parent company of Community Health Center, Inc. (“CHC”), a federally qualified health center. MWHS plays an integral role in CeCN’s day-to-day operations by providing back-end support. Historically, CeCN was an innovation of CHC. Many of the policies and procedures that govern CeCN’s business operations come from MWHS. Similarly, many of the policies and procedures that govern CeCN’s healthcare delivery come from CHC.

    These policies and procedures are available to all CeCN employees on the internal SharePoint page and CeCN provides training, as described in the ‘Training and Education’ section of this document. Further, CeCN, MWHS and CHC review their policies and procedures at regular intervals to ensure relevancy and accuracy. All revisions are posted on the internal SharePoint page and are available to all CeCN employees. Each CeCN employee is responsible for adhering to CeCN’s policies and procedures.

    • A. Standards of Conduct/Conflict of Interest:

      Each employee and Board member accepts a duty of loyalty to CeCN and agrees to always act in the best interest of CeCN to maintain both the integrity and appearance of integrity of CeCN. CeCN has implemented a Standard of Conduct and Conflict of Interest Policy for Board Members, officers, employees, students/interns and agents. The policy sets forth the process for identifying and disclosing conflicts of interests and outlines standards of conduct involving the duty of confidentiality, honesty, and political activities as well as others.

    • B. CeCN has the following categories of policies and procedures to address compliance:
      1. Operational and Clinical Policies – CeCN adheres to extensive operational and clinical policies and procedures that include, but are not limited to, credentialing, human resources management, information management and security, finance, provision of care and telehealth.
      2. Health Information Management (HIPAA compliance) – CeCN adheres to a comprehensive set of policies and procedures that ensure compliance with the Health Insurance Portability and Accountability Act of 1996, as amended by sections 13400 through 13424 of the Health Information Technology for Economic Clinical Health Act and related regulations (“HIPAA”). These policies and procedures govern the use and disclosure of protected health information (“PHI”) and electronic protected health information are made available to all employees including student interns with access to PHI. Further, CeCN provides thorough HIPAA training to all workforce members on an annual basis.When acting as a management services organization, CeCN follows the HIPAA policies and procedures of the healthcare provider to which it provides services to the extent that CeCN is carrying out obligations of that covered entity (e.g., responding to records requests, requests for an amendment, etc.).
    • C. Nondiscrimination

      CeCN will not discriminate in the delivery of services based on a patient’s race, color, religion, gender, sexual orientation, age, disability, national origin, military status, genetic information, ancestry, health status, or need for health services.

      CeCN will not discriminate against, intimidate or retaliate against any employee based on race, color, religion, gender, sexual orientation, age, disability, national origin, military status, genetic information, ancestry, health status, or need for health services.

      Where applicable, CeCN will comply with all applicable Federal and State Laws and regulations including Title VI of the Civil Rights Act of 1964; Title IX of the Education Amendments of 1972 (regarding education programs and activities); the Age Discrimination Act of 1975; the Rehabilitation Act of 1973; the Americans with Disabilities Act of 1990 as amended; and section 1557 of the Patient Protection and Affordable Care Act.

      CeCN requires the same commitment to nondiscrimination from its contractors and vendors.

    • D. Fraud, Waste and Abuse

      CeCN employees and contractors will abide by all fraud, waste, and abuse laws and regulations, if applicable, and have the responsibility to detect and prevent, to the extent practicable, fraud, misappropriation of CeCN resources and other inappropriate conduct, including, but not limited to:

      • Any dishonest or fraudulent act;
      • Forgery or alteration of any document, check, deposit ticket or amount belonging to, or submitted on behalf of, CeCN;
      • Misappropriation of funds, supplies, or other assets of CeCN;
      • Impropriety in the handling or reporting of money or financial transactions;
      • Personally benefitting as a result of insider knowledge of CeCN activities;
      • Self-dealing or misappropriation of corporate opportunities from CeCN;
      • Destruction, removal, or inappropriate use of records, furniture, equipment or other property of CeCN;
      • Unlawfully accepting or seeking anything of material value from contractors, vendors, or other persons or entities providing services, funding or materials to CeCN;
      • Inducements for providing referrals, services, medication, and equipment;
      • Providing false or misleading information to participate in any reimbursement programs;
      • Providing false or misleading information to secure payment; and
      • Submitting false, fraudulent, or intentionally misleading claims for services not delivered, for services different from what actually was delivered; or that do not follow applicable legal requirements.

      Any person associated with CeCN who has a good faith belief that potential or actual fraud, misappropriation or fraudulent conduct has occurred must report it immediately to their supervisor, manager, or the Compliance Officer.

    • E. Billing Practices
      1. If CeCN bills a state or federal government healthcare program, the billing practices of CeCN will comply with applicable federal and state billing and fraud and abuse laws and the contractual obligation contained in the various payer agreements under which it operates.If payment is to be made under a grant, CeCN will comply with all requirements under the grant documents.

        All billing will be based upon accurate charges for services actually rendered.

      2. CeCN will maintain required records and ensure that employees are trained in such requirements, including but not limited to:
        • i. Adequate documentation of patient demographic and insurance information;
        • ii. Basic working knowledge of coding procedures using ICD-10-CM and CPT® coding guidelines when relevant. The CPT® codes explain what and the ICD-10-CM codes explain why provider services were performed.
    • F. Compliance With Managed Care Regulations and Rules

      To the extent that CeCN contracts with a managed Medicare or Medicaid organization, CeCN will comply with applicable state and federal managed care regulations, rules and sub-regulatory guidance as set forth in each payer agreement.

    • G. Screening for Excluded Persons

      CeCN will not employ, or subcontract with an individual or entity, or have persons with ownership or control interests, who have been convicted of criminal offenses related to their involvement in Medicaid, Medicare, or social services programs under Title XX of the Social Security Act, and thus have been excluded from participation in any federal health care program under §§1128 or 1128A of the Act (or with an entity that employs or contracts with such an individual) or any relevant state health care program.

      1. Employees – Prior to hire, MWHS’s HR team performs a check of government exclusion databases to ensure that CeCN is not hiring any individual who has been excluded or otherwise declared ineligible to participate with federal or state health care programs.
      2. Vendors – CeCN follows MWHS’ Contract Management Policy for all vendor contracts that provides a framework for understanding the process of systematically and efficiently managing contract creation, execution, and analysis for the purpose of maximizing financial and operational performance and minimizing risk. This policy includes a checklist consisting of several items that outline and provide detailed guidance on initiating a new or amending an existing contract using CeCN’s Contract Management system. Prior to CeCN signing a contract with any new vendor, CeCN performs a check of government exclusion databases to ensure that CeCN is not doing business with any vendor that has been excluded or otherwise declared ineligible to participate with federal or state health care programs.
      3. Specialists – CeCN’s Credentialing Policy outlines the credentialing standards set by the National Committee on Quality Assurance (NCQA). As part of its credentialing process, CeCN performs a check of government exclusion databases to ensure that CeCN is not engaging any Specialist who has been excluded or otherwise declared ineligible to participate with federal or state health care programs.
    • H. Record Retention

      CeCN shall retain medical and related financial records for a period of 10 years after the date of service or, in the case of a minor, three years after the minor reaches the age of majority or 10 years from the date of service, whichever is later. All other business records are subject to CeCN’s document retention schedule.

  2. Designation of Compliance Officer

    While compliance is the responsibility of the Board, employees, agents and contractors, the Compliance Officer is responsible for overseeing the Compliance Program. The Compliance Officer reports to the President and has direct and independent access to the Board. The duties and responsibilities of the Compliance Officer shall include, but are not limited to:

    • Assuring development, implementation and enforcement of written policies relating to relevant state and federal legal and regulatory issues and matters involving ethical and legal business practices;
    • Collaborating with the Department of Human Resources to develop and implement education and training on compliance for CeCN personnel upon hire and ensuring that independent contractors receive or verify completion of acceptable training;
    • Providing written acknowledgement of any compliance inquiry and/or complaint and conduct a prompt investigation of the subject matter;
    • Responding to the complainant, if known, of findings and corrective action, if any, that have been recommended or implemented;
    • Maintaining a record of all inquiries and responses and submitting at least a quarterly summary report to the Board;
    • Providing guidance and interpretation to the Board as appropriate, on matters related to the Compliance Program; and
    • Planning and overseeing periodic audits of billing activities and operations and recommending actions in response to audit results.
    • Preparing an annual summary report for CeCN’s Board.

  3. Education and Training

    Access to a copy of the Compliance Program shall be provided or made available to members of the Board, employees, agents, contractors and vendors with which CeCN conducts business. As part of an employee orientation program, CeCN will inform each new employee about the Compliance Program and the procedures by which they may report areas of suspected non-compliance. CeCN will provide annual compliance training to the Board, employees and Specialists.

  4. Communication

    CeCN employees are encouraged to seek clarification regarding any aspect of the Compliance Program at any time from their supervisor or the Compliance Officer.

    Employees, students/interns, agents, contractors and Specialists are required to report any actual or suspected violation of CeCN’s policies, standards of conduct, or any laws applicable to CeCN. Any suspected or actual violation may be reported to any of the following:

    • The individual’s immediate supervisor;
    • The supervisor’s supervisor;
    • The Compliance Officer;
    • The confidential compliance email: [email protected]; or
    • The anonymous and confidential “hotline” for compliance concerns (860-344-7011 ext. 5614).

    The Compliance Officer monitors the confidential email and hotline.

    CeCN will take no disciplinary or retaliatory action because an employee reports any compliance concerns internally or externally.

    Once a compliance issue is reported, the Compliance Officer shall provide written acknowledgement of the inquiry and/or complaint (if not filed anonymously) and conduct a prompt investigation of the subject matter. The Compliance Officer shall initiate an investigation into the matter as quickly as possible but in no event later than ten days after receipt of an inquiry or complaint.

    The investigation will adhere to all applicable CeCN/MWHS policies regarding personnel action to be taken. Upon completion of the investigation, the Compliance Officer shall provide a written or verbal report to the complainant, if known, of the findings and corrective actions, if any, that have been recommended or implemented. The Compliance Officer shall maintain a record of all inquiries, complaints and responses.

    The Compliance Officer will notify CeCN’s President of any alleged compliance allegations that are serious in nature and could result in potential consequences. For routine compliance matters, the Compliance Officer will report the conclusion of his or her investigation findings to CeCN’s Board Chairman at regular intervals. To the extent practical and appropriate, efforts will be made to maintain the confidentiality of such investigations and the information gathered.

  5. Risk Assessment, Internal Monitoring and Auditing

    Risk Assessment

    A compliance risk assessment is a risk assessment process that looks at risk to the organization stemming from violations of law, regulations, or other legal requirements. CeCN will periodically perform a compliance risk assessment to scan for unidentified or new risks, which may be prompted by changes in the law, new enforcement actions, or internal monitoring results. Identified items will be subject to on-going monitoring in CeCN’s internal audit plan.

    Key findings from internal and external audits will be reported to CeCN’s Board on a regular and as needed basis.

    Billing Reviews and Monitoring

    If CeCN bills government payers, to comply with its obligations as a participant in Medicare, Medicaid and other government-funded health care payment programs, CeCN will conduct internal audits and/or monitoring activities to ensure the accuracy of claims and reported information reported to CeCN’s payers, as described in sections 1.D and 1.E above.

    Further, CeCN’s on-going monitoring includes its monthly screening of Specialists against the LEIE and State Medicaid exclusion list, regular screening of State licensure and certification databases, and regular review of policies and procedures.

    Annual Review of Compliance Program

    To ensure adherence to CeCN’s policies and procedures, and to identify areas of potential risk which may require special attention, CeCN shall conduct, at least annually, a review of the Compliance Program either independently or in conjunction with its parent, MWHS. The Compliance Officer shall participate in this annual review.

  6. Disciplinary Standards

    A violation of CeCN’s Compliance Program or failure to comply with CeCN’s Standards of Conduct may be considered a serious breach by an employee and the offending employee may be subject to discipline up to and including termination in accordance with MWHS’s HR policies and procedures. Responses to violations committed by other persons associated with CeCN, such as contractors will be assessed by the Compliance Officer and appropriate action will be determined on a case-by-case basis depending on the nature and circumstances of violation.

  7. Corrective Action

    When a compliance issue has been identified through routine monitoring, by report, by an investigation or otherwise, the Compliance Officer will ensure that appropriate corrective action is taken. A corrective action plan will be developed by the director/supervisor of the involved employee’s department, in collaboration with and with approval from the Compliance Officer. The director/supervisor is responsible for implementing and monitoring the corrective action plan and keeping the Compliance Officer appraised of the status.

    A corrective action plan is designed to rectify the identified compliance issue, but also, when appropriate, to address process and system issues to prevent or reduce the likelihood of the issue’s recurrence. In accordance with CeCN’s policies, the corrective action may require the provision of training, the reassignment or reorganization of duties or functions, personnel action, termination of contractual relationships, repayment, external disclosures to the appropriate oversight body of the risk issue and action taken, or any other corrective action deemed appropriate to effectively address the compliance issue.

    The Compliance Officer shall maintain records of the investigation, actions taken and remediation of compliance issues.