HealthONE Colorado Care Partners ACO LLC Compliance Plan

HealthONE Colorado Care Partners ACO LLC ("hereafter referred to as ACO") has established its Compliance Plan to address matters of ethical business conduct and demonstrate compliance with health care law and regulatory requirements in accordance with 42 CFR § 425.300 (the Compliance Program). ACO participates as an HCA affiliate in the HCA Healthcare (HCA) Ethics and Compliance Program. Certain aspects of the Compliance Program are carried out through a management services agreement between an affiliate of HCA and ACO.

The Compliance Program includes the following:

A designated compliance official who reports directly to the organization1s governing body.

ACO is governed by a Board of Managers (the "Board"), has participants that are providers of medical services, and clinical and administrative leadership including an Executive, a Medical Director, a Quality Assurance/Improvement Officer and a Compliance Officer. The Compliance Officer oversees the Compliance Program, does not serve as legal counsel to the organization, and reports directly to the governing body.

The Compliance Officer's role is to:

  • Provide leadership for the Compliance Program;
  • Oversee and monitor the implementation and effectiveness of the Compliance Program;
  • Be a resource and provide guidance on laws, regulations, and policies applicable to the Compliance Program;
  • Report periodically to the Board on Compliance Program matters;
  • Develop and distribute compliance policies and procedures;
  • Develop, coordinate and deliver Compliance Program training;
  • Conduct periodic reviews and monitoring of the Compliance Program to ensure compliance with policies and/or to identify issues, implementing appropriate corrective actions as needed;
  • Prepare reports on the implementation and effectiveness of the Compliance Program;
  • Maintain records related to the Compliance Program;
  • Ensure a system is in place for confidential, good-faith reporting and investigation of suspected violations of Compliance Program standards along with applicable laws, rules and regulations.

At least annually, the Compliance Officer shall report to the Board of Managers of HealthONE Colorado Care ACO LLC on the status of the Compliance Program including Compliance Program updates, updates on any applicable laws, rules, and regulations, reported incidents, investigations, and monitoring activities. The report will be documented in minutes of such Board meeting. The Compliance Officer may make additional reports at quarterly Board meetings or as needed as determined by the Compliance Officer or as further requested by the Board.

Mechanisms for identifying and addressing compliance problems related to the organization's operations and performance (e.g., internal reporting, monitoring or audit processes).

HCA's Internal Audit Department routinely conducts audits to identify and address issues that may have potential regulatory or compliance implications. Responsible Executives, subject matter experts in various aspects of healthcare regulatory compliance, undertake monitoring efforts in support of company policies and compliance in general. Internal Audit, in consultation with the HCA Corporate Ethics and Compliance Department and Responsible Executives, conducts an assessment each year of the top compliance concerns and focuses its reviews accordingly. The ACO will also conduct self­ monitoring. The effectiveness of the Compliance Program is, in part, assessed in these ongoing efforts.

Through its management services agreement with HCA, ACO uses an Internal Compliance Reporting System to manage reporting of issues that may pose a significant compliance risk. Among those applicable to ACO are issues involving fraud waste and abuse (FWA) (anti-kickback and false claims), patient inducement, licensure, physician relationships, patient privacy, audits by government regulators, and other potential violations of laws applicable to Federal healthcare programs.

Reporting through the Internal Compliance Reporting System is designed to permit the aggregation, trending, and reporting of data increasing the likelihood of consistent application of corrective actions. The process for handling issues that are reported internally is overseen by HCA's Director of Internal Compliance Reporting in close coordination with the relevant Responsible Executive. Any such issues identified will be communicated to the Compliance Officer for resolution.

Potential compliance problems may also be identified by employees and others interacting with the organization. Anyone aware of violations or suspected violations of laws, regulations, standards, and the conditions of participation, or company policies and procedures, must report them immediately to a supervisor or member of management, Human Resources, the Compliance Officer, the Ethics Line, or HCA's Chief Ethics and Compliance Officer.

For all identified and reported compliance concerns, an investigation will occur when potential non­ compliance is communicated to the Compliance Officer. The Compliance Officer shall conduct a thorough investigation and may utilize the assistance of others to perform the investigation.

Once the investigation is complete, appropriate corrective action will be undertaken to prevent future occurrences. Corrective action will be communicated with the appropriate individuals or areas of the organization. Any necessary training will be developed and implemented. Disciplinary action will be taken if deemed necessary. All activities and actions taken will be documented.: In circumstances where a voluntary self-report is required, the organization will promptly report to the appropriate authority.

A method for reporting suspected problems to the Compliance Officer

Through its agreement with HCA, ACO uses an internal reporting mechanism, in which callers may choose to remain anonymous, called the Ethics Line. Operation of the Ethics Line involves contracting with an outside vendor to answer the toll-free phone number, analyzing new cases, either investigating or arranging for the investigation of cases, and reviewing investigations and corrective action. In all cases, feedback regarding the outcome of the case is available to the caller. These cases are tracked through an HCA Corporate data base. They will be tracked on a log maintained by the Compliance

Officer along with any other issues of compliance concern brought to the Compliance Officer's attention.

The Ethics Line is available to anonymously report suspected problems. The Ethics Line accommodates numerous languages and is available toll-free, 24 hours a day, 7 days a week at 1-800-455-1996 or through an online service. This information is available to employees on the HCA intranet, in the Code of Conduct and in other publications located in facilities. The contact information for the Ethics Line is available to participants, providers, suppliers and contractors via HCA's internet site and in the HCA Code of Conduct which is also posted on HCA's internet site. Contact information for and use of the Ethics Line is also addressed in compliance training.

There is no retribution or discipline for anyone who reports a concern in good faith. Any colleague who deliberately makes a false accusation with the purpose of harming or retaliating against another colleague is subject to discipline.

The Compliance Officer may raise concerns directly with the Board as necessary.

Compliance training

Employees are required to complete Code of Conduct orientation training within 30 days of hire and refresher training on an annual basis thereafter. The focus of the orientation training is a comprehensive introduction to the HCA Code of Conduct. This includes a review of what constitutes program violations, how to recognize violations, and how to report issues. Annual refresher training has a different focus each year, with themes such as doing the right thing and how all colleagues are connected to the HCA mission and values.

The Compliance Officer helps to ensure that participants, contractors, providers and suppliers are aware of the existence of the Compliance Program and are notified of revisions to compliance requirements resulting from regulatory changes that may impact their services to ACO. The Code of Conduct and other HCA policies are available through the HCA internet site.

Specialized compliance training is developed in particular risk areas by HCA's Responsible Executives. The Compliance Officer works with Responsible Executives to ensure that employees, contractors, participants, and providers and suppliers are aware of the standards that apply to them in their interactions with ACO and that any applicable specialized training is made available to these groups as needed.

The Compliance Officer will periodically update Compliance Program training materials to respond to changes in the law and industry that impact services provided by the organization.

Training may be delivered in different formats including in meetings or other in-person sessions, via WebEx or teleconference, or through the HealthStream Learning Center learning management system (HealthStream). Additional education and communications may distributed in email.

The Compliance Officer monitors completion of required training through HealthStream or in other live and/or recorded formats with attendance tracked and retained by the Compliance Officer.

Requirement for the ACO to report probable violations of law to an appropriate enforcement agency.

ACO acknowledges that it is required to report probable violations of law to an appropriate enforcement agency. Where an internal investigation substantiates a reported violation, it is the policy of the organization to initiate corrective action, including, as appropriate, making prompt restitution of any overpayment amounts, notifying the appropriate governmental agency, instituting whatever disciplinary action is necessary, and implementing systemic changes to prevent a similar violation from recurring in the future.

ACO follows HCA's company process for analyzing issues to determine if a probable violation of law has occurred. The includes engaging Responsible Executives, members of the Internal Compliance Reporting Team, and legal counsel, both internal and external, as necessary to determine whether applicable law may have been violated. The appropriate experts will advise on required reporting and who will do so on behalf of the organization.

The Compliance Officer has the authority to report to CMS, its designee, and law enforcement and will do so upon advice of legal counsel.