AMCH PPS Compliance Program Training: Instructional Webinar August 19,

Agenda Compliance Program Training overview –The PPS Leads obligation to provide training –AMCH PPS compliance training video –The future of Compliance Training Determining who must be trained (Affected Persons) AMCH PPS Training Template Reporting and due dates Next Steps Q & A 2

Compliance Program Training The PPS Leads obligation to provide training 18 NYCRR 521.3(c)(3) (Element #3) requires “training and education of all affected employees and persons associated with the provider (PPS Lead)” on the compliance program. Those determined to be “affected employees and persons” may be different during different phases of DSRIP implementation. It is up to the PPS Lead to undertake a reasonable analysis to identify who is “affected” and provide training and education accordingly. While the PPS Lead is responsible for the training and education on its compliance program, the PPS Lead is not required to provide the training and education itself. 3

AMCH PPS Compliance Training Video Compliance Training elements: Brief background of the DSRIP waiver Using the PPS website as a resource Effective Compliance Programs Selected Fraud & Abuse laws Protecting patient privacy Reporting potential compliance concerns o&feature=sharehttps:// o&feature=share 4

The Future of Compliance Training 18 NYCRR 521.3(c)(3) (Element #3) continued: OMIG expects that PPS Leads’ training and education plans will need to evolve and be revised as the DSRIP program develops. It is recommended that PPS Leads consider this when they evaluate their compliance programs. 5

Determining who must be trained (Affected Persons) 18 NYCRR 521.3(c)(3) (Element #3): The PPS Lead is responsible for training and education of all affected employees, persons associated with the provider (PPS Lead), its executives and its governing body members on compliance issues and expectations. “Persons associated with the provider” include performing providers within the PPS network who are or may be eligible to receive DSRIP funds. 6

Affected Persons: Defined Affected Person: all persons associated with a provider who provide items or services, medical direction, referral or prescription including: its executives and its governing body members; employees, contractors, subcontractors or volunteers; other persons associated with the provider "including performing providers within the PPS network" or members of its medical staff; working in any capacity where NYS DSRIP payments are sought. Each Partner Organization is responsible for identifying all persons and parties under their direction, supervision or control, or who otherwise directly or indirectly supports activities funded by the NYS DSRIP program submitted by Albany Medical Center Hospital and its Partner Organizations. These activities may extend to providers' operations other than just billing and payments. At a minimum, participating organizations should consider persons and parties who conduct activities in support of the DSRIP program and responsibilities articulated by any executed Partner Organization Agreement and Master Project Agreement including, but not limited to: billings; payments; medical necessity and quality of care; governance; mandatory reporting; credentialing; and other risk areas that are or should, with due diligence, be identified by the provider or partner organization. All Affected Persons should receive training as part of new employee orientation, at least annually and as required by changes to roles, responsibilities or requirements of program participation occur. 7

Attesting to training completion Your Compliance Officer must complete the AMCH PPS Sign in sheet and Attestation 8

9 AMCH PPS Training Template Name of TrainingCompliance Program Training Description of Training Summary review of the AMCH PPS Compliance Program Materials Provided Required Documentation Training template, sign in sheets with signed attestation Project(s) Association N/A Staff Titles/ Roles REQUIRED to Complete Training OPTIONAL Staff Titles/ Roles to Complete Training All Affected Employees N/A As a contract requirement, evidence of training must be submitted to the PMO within 15 days of the end of each quarter. Please see below for the DY2 reporting schedule. Brief course evaluations will be sent to all participants and should be completed according to the schedule below. Course evaluations are optional, but strongly encouraged so we can continue to provide the highest quality training possible to our workforce. Training ScheduleCourse Evaluation Schedule Quarter Training Completed ByReporting due By Quarter Evaluation Sent On of BeforeEvaluation Completed By DY2Q2 9/30/201610/15/2016 DY2Q2 9/30/201610/15/2016 DY2Q312/31/20161/15/2016DY2Q312/31/20161/15/2016 DY2Q4 3/31/20164/15/2016 DY2Q4 3/31/20164/15/2016 PMO ContactContact Contact Phone Todd How to Submit Reporting 1. Print "Sign In" sheet(s), collect information for all trained staff and sign attestation on each page. 2. Save a copy of your training template using the naming convention "Delivery Year and Quarter_TT_Training Name_Organization Name" For example: "DY2Q2_TT_Self-Management_AlbanyMedicalCenter" (Correct "DY" is at the top of this page) 3. Scan all sign-in sheets into one file (if possible) and save using the naming convention "Delivery Year and Quarter_SI_Training Name_Organization Name" 4. training template, sign in sheets, and any other required documentation to with subject line "Training Report"

The AMCH PPS Sign-in and Attestation page(s) can be ed to: Subject line: Training Report Or mailed to: Center for Health System Transformation Attn: Compliance Training 1275 Broadway Menands, NY Reporting to the PMO upon completion of training 11

Reporting Due Date(s) Compliance Training is an ongoing required deliverable in your contract. Initial training for all of your affected employees must be completed by 9/30/16. You must submit your completed Sign-in sheet and Attestation by 10/15/16 to receive your incentive payment and to remain an active partner in any DSRIP initiative. Starting 10/1/16 all new affected persons hired must receive DSRIP compliance training within the current DSRIP quarter they are hired into. All Compliance trainings must be reported in the DSRIP quarter they were completed to receive credit. 12

Reporting AMCH PPS Partner Organization Agreement: Section 9.7.: Suspension from Project Participation and PPS Operations Due to Legal or Patient Safety Risks. If AMCH reasonably determines that Partner Organization has failed to comply with applicable law or regulation or its obligations under this Agreement and that such failure poses a substantial and immediate risk of legal noncompliance by AMCH or other Partner Organizations or a risk of harm to patients cared for in a PPS Project, AMCH shall have the right to immediately suspend Partner Organization from participation in a Project or PPS operations by delivering written notice to Partner Organization stating the reasons for the suspension. AMCH shall have the discretion to continue such suspension until such noncompliance is remedied to the reasonable satisfaction of AMCH. 13

Next Steps: To access the: 1. The compliance training video YouTube link 2. The slides and narrative associated with the compliance training video 3.The AMCH PPS Training Template, Sign-in and Attestation page 4. The slides from this presentation 14

Go to: Albanymedpps.org Committees tab Audit and Compliance Additional documents 15

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Contact information: Website: Reporting PMO contact: Todd Faubel

18 Q & A