Compliance Policy

Approved and Final: 12/27/2023

ConferMED Compliance Program

Introduction 

Scope of Compliance Program

Clinical Services

Consulting Services

Framework

1. Ensuring Compliance Through Policies and Procedures 
   1. ConferMED’s Policies and Procedures
      1. Operational Policies
      2. Clinical Policies
      3. Health Information Management (HIPAA) Policies
   2. Nondiscrimination 
   3. Standards of Conduct
   4. Fraud, Waste and Abuse
   5. Billing Practices
   6. Compliance with Managed Care Contracts, Rules and Regulations
   7. Screening for Excluded Persons
   8. 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

Scope of Compliance Program: This Compliance Program, including all standards, policies, and procedures referenced herein, apply to all operations, programs, and services of ConferMED, PC and ConferMED of California, PC (collectively “ConferMED”).

When applicable, this program applies to members of ConferMED’s owner, officers, employees, agents, and contractors. This Compliance Program is intended to demonstrate ConferMED’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. 

Clinical Services: ConferMED’s unique clinical service delivery model focuses on supplementing primary care with specialist consultations. It does this in two ways: (1) asynchronous electronic consultations between a ConferMED specialist and a primary care provider (“PCP”) through a secure platform (“eConsult”); and (2) on request of the PCP, a ConferMed specialist will conduct a live telehealth session with the patient for consultation purposes (“Live Telehealth”) (collectively “Clinical Services”). In each instance, ConferMED works directly with the PCP. With respect to payment for the Clinical Services, ConferMED (1) bills a third-party or government payer; (2) the PCP or related clinic pay for the services; or (3) a grant covers the cost of the services.

Consulting Services: ConferMED also provides consulting services to healthcare providers, including but not limited to training and professional development (“Consulting Services”). Consulting Services do not require the use of or access to protected health information and the healthcare providers pay ConferMED directly for such services.

Framework: This program is based on the seven elements of an effective compliance program as outlined by the 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.

Elements

1. Ensuring Compliance Through Policies and Procedures

   ConferMED is a medical practice that offers the Clinical and Consulting Services described above. All ConferMED’s backend operations are carried out by Community eConsult Network, Inc. (“CeCN”) under a management services agreement. ConferMED relies on CeCN’s operational policies and procedures and Compliance Program for those aspects of ConferMED’s operations handled by CeCN. These policies and procedures are available to ConferMED staff. Clinical policies and procedures are available to contracted specialists who carry out the Clinical Services (“Specialists”). ConferMED reviews its clinical policies and procedures at regular intervals to ensure relevancy and accuracy. All revisions are made available to ConferMED staff and contractors, when applicable.

   1. ConferMED’s Policies and Procedures

      1. Operational Policies – ConferMED follows the operational policies of CeCN, which manages ConferMED’s operations on a day-to-day basis. CeCN adheres to extensive operational policies and procedures that include, but are not limited to, human resources management, information management and security, and finance. Policies relevant and applicable to ConferMED staff.

      2. Clinical Policies – ConferMED maintains policies that address credentialing, provider monitoring and care delivery. Specialists have access to these policies.

      3. Health Information Management (HIPAA compliance) – ConferMED adheres to an extensive 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 staff including student interns, and volunteers with access to access to PHI. ConferMED has HIPAA Privacy Policies and Procedures and has adopted CeCN’s HIPAA Security Policies and Procedures.

   2. Nondiscrimination

      ConferMED 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.

      ConferMED 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, ConferMED 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.

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

   3. Standards of Conduct:

      Each employee and owner accept a duty of loyalty to ConferMED and agrees to always act in the best interest of ConferMED to maintain both the integrity and appearance of integrity of ConferMED. ConferMED has implemented the Standard of Conduct set forth below for employees, owners and Specialists.

      1. ConferMED staff, owners and Specialists shall comply with all applicable laws, regulations or other government requirements in carrying out tasks for ConferMED.
      2. ConferMED staff, owners, Specialists or vendor shall report any suspected fraud, waste, abuse, any violation of a legal or ethical obligation or any unfair or improper treatment of staff, clients or patients.
      3. ConferMED staff, owners, Specialists and vendors shall not file a false or fraudulent claim for payment to the federal, state or local government.
      4. ConferMED staff, owners, Specialists and vendors shall treat all confidential and proprietary information as confidential.
      5. Specialists shall perform eConsults in accordance with (i) the protocols developed by ConferMED, to which ConferMED will provide access, and (ii) generally accepted professional standards.
      6. Specialists shall render eConsults and Live Telehealth in a competent, ethical, respectful and professional manner and in compliance with all applicable federal, state, and local laws and regulations. 
      7. ConferMED staff, owners, Specialists and vendors shall treat all people with whom they interact for ConferMED business with dignity and respect.
   4. Fraud, Waste and Abuse

      ConferMED staff, owners, Specialists and vendors 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 ConferMED 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, ConferMED; 
      • Misappropriation of funds, supplies, or other assets of ConferMED;
      • Impropriety in the handling or reporting of money or financial transactions;
      • Personally benefitting as a result of insider knowledge of ConferMED activities;
      • Self-dealing or misappropriation of corporate opportunities from ConferMED;
      • Destruction, removal, or inappropriate use of records, furniture, equipment or other property of ConferMED;
      • Unlawfully accepting or seeking anything of material value from contractors, vendors, or other persons or entities providing services, funding or materials to ConferMED; 
      • 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 ConferMED 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. 

   5. Billing Practices 

      1. If ConferMED bills a state or federal government healthcare program, the billing practices of ConferMED 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, ConferMED will comply with all requirements under the grant documents.

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

      2. ConferMED will maintain required records and ensure that staff and contracted specialists are trained on such requirements, including but not limited to:
         1. Adequate documentation of patient demographic and insurance information;
         2. Basic working knowledge of coding procedures using ICD and CPT coding guidelines when relevant. The CPT codes explain what and the ICD codes explain why provider services were performed.
   6. Compliance With Managed Care Contracts, Rules and Regulations

      To the extent that ConferMED contracts with a managed Medicare or Medicaid organization, ConferMED and its subcontractors (including Specialists) will comply with applicable state and federal managed care regulations, rules and sub-regulatory guidance. Additionally, in the delivery of services, Specialists agree to comply with ConferMED’s obligations under ConferMED’s managed care contract agreements and any applicable provider manual to the extent that ConferMED makes Specialist aware of such obligations. Additionally, with respect to managed Medicaid, ConferMED and its subcontractors agree to serve enrollees in any State Agency Medicaid Program and, in doing so, to comply with all the provisions of any applicable Medicaid Addendum to the managed Medicaid agreement.

   7. Screening for Excluded Persons

      ConferMED 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, ConferMED performs a check of government exclusion databases to ensure that ConferMED is not hiring any individual who has been excluded or otherwise declared ineligible to participate with federal or state health care programs.
      2. Vendors – ConferMED’s management services organization, CeCN, handles on-boarding of all vendors. CeCN follows a 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 ConferMED signing a contract with any new vender, CeCN’s 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 performs credentialing on all Specialists as ConferMED’s management services organization and it does so in accordance with CeCN’s policy. 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.
   8. Record Retention

      ConferMED shall retain medical and 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.

2. Designation of Compliance Officer 

   While compliance is the responsibility of the staff, owners, Specialists and vendors, the Compliance Officer is responsible for overseeing the Compliance Program. ConferMED’s Compliance Officer functions are carried out by its management services organization, CeCN. 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;
   • Ensuring the development and implementation of education and training on compliance for ConferMED staff and Specialists upon hire or engagement, except that Specialists may complete a Compliance Training Attestation to provide evidence of completion of adequate compliance, HIPAA and fraud waste and abuse 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 submit at least an annual summary report to the owners;
   • Providing guidance and interpretation, as appropriate, on matters related to the Compliance Program; and
   • To the extent that ConferMED bills insurance companies or government payers, planning and overseeing periodic audits or monitoring activity of ConferMED’s operations and recommending actions in response to audit results. 

   ConferMED’s Compliance Office function is carried out by CeCN’s designated Compliance Officer.

3. Education and Training 

   Access to a copy of the Compliance Program shall be provided or made available to staff, owners, Specialists and vendors with which ConferMED conducts business. As part of its orientation program, ConferMED 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 all ConferMED staff and will ensure that Specialists have completed adequate training by completing ConferMED’s training or attesting to the completion of comparable training.

4. Communication 

   ConferMED staff, owners, Specialists or vendors are encouraged to seek clarification regarding any aspect of the Compliance Program at any time from their supervisor or the Compliance Officer.

   Staff, owners, Specialists or vendors are required to report any actual or suspected violation of ConferMED policies or any laws applicable to ConferMED. Any suspected or actual violation may be reported to any of the following:

   • The individual’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.

   ConferMED 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 ConferMED/CeCN 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 ConferMED’s CEO 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 ConferMED’s CEO 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, on behalf of ConferMED, 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.

   Billing Reviews

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

   Further, ConferMED’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 ConferMED’s policies and procedures, and to identify areas of potential risk which may require special attention, ConferMED shall conduct, at least annually, a review of the Compliance Program through CeCN. The Compliance Officer shall participate in this annual review.

6. Disciplinary Standards 

   A violation of ConferMED’s Compliance Program 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 HR policies and procedures. Responses to violations committed by other persons associated with ConferMED, 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 ConferMED’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.