BETWEEN THE
OF THE
AND
I.
PREAMBLE
Dallas County Hospital District d/b/a Parkland Health and Hospital System
(Parkland) hereby enters into this Corporate Integrity Agreement (CIA) with the Office of
Inspector General (OIG) of the United States Department of Health and Human Services
(HHS) to promote compliance with the statutes, regulations, and written directives of
Medicare, Medicaid, and all other Federal health care programs (as defined in 42 U.S.C.
1320a-7b(f)) (Federal health care program requirements). On September 28, 2011,
Parkland entered into a Systems Improvement Agreement (SIA) with the Centers for
Medicare and Medicaid Services. In accordance with the terms of the SIA, in November
2011 Parkland retained an Independent Consultative Expert (ICE). As amended by the
parties to the SIA, the SIA requires completion of a Medicare certification survey
(Survey) on or before August 31, 2013. Contemporaneously with this CIA, Parkland is
entering into a Settlement Agreement with the United States.
II.
A.
The period of the compliance obligations assumed by Parkland under this
CIA shall be five years from the effective date of this CIA. The Effective Date shall be
the date on which the final signatory of this CIA executes this CIA. Each one-year
period, beginning with the one-year period following the Effective Date, shall be referred
to as a Reporting Period.
B.
Sections VII, X, and XI shall expire no later than 120 days after OIGs
receipt of: (1) Parklands final annual report; or (2) any additional materials submitted by
Parkland pursuant to OIGs request, whichever is later.
C.
1.
b.
c.
Notwithstanding the above, this term does not include part-time or per diem
employees, contractors, subcontractors, agents, and other persons who are not reasonably
expected to work more than 160 hours per year, except that any such individuals shall
become Covered Persons at the point when they work more than 160 hours during the
calendar year.
2.
Billing and Reimbursement Covered Persons includes all Covered
Persons involved, directly or in a supervisory role, in the preparation or submission of
claims for reimbursement from, or cost reports to, any Federal health care program.
3.
Clinical Quality Covered Persons includes all Covered Persons
involved in the delivery of patient care items or services at Parkland or involved in
quality assurance or the monitoring of clinical quality at Parkland.
III.
Parkland shall establish and maintain a Compliance Program that includes the
following elements:
A.
1.
Compliance Officer. Parkland has appointed a Chief Compliance
Officer (Compliance Officer). Parkland shall maintain a Compliance Officer for the term
of the CIA. The Compliance Officer is, and shall continue to be, responsible for
developing and implementing policies, procedures, and practices designed to ensure
compliance with the requirements set forth in this CIA and with Federal health care
2
Safety Officer shall be responsible for developing and implementing policies, procedures,
and practices designed to ensure compliance with professionally recognized standards of
care. The Chief Quality and Safety Officer shall be a member of senior management of
Parkland, shall report directly to the Chief Medical Officer of Parkland, shall make
periodic (at least quarterly) reports regarding quality assurance matters directly to the
Quality and Safety Committee of the Board, and shall be authorized to report on such
matters to the Board at any time. The Chief Quality and Safety Officer shall not be
subordinate to the General Counsel or Chief Financial Officer. The Chief Quality and
Safety Officer shall be responsible for monitoring the day to day quality of care and
patient safety activities engaged in by Parkland. Any non-quality assurance job
responsibilities of the Chief Quality and Safety Officer shall be limited and must not
interfere with the Chief Quality and Safety Officers ability to perform the activity
outlined in this CIA. The Chief Quality and Safety Officer shall have sufficient quality
assurance experience to perform the responsibilities described in this paragraph.
Parkland shall report to OIG, in writing, any change in the identity of the Chief
Quality and Safety Officer, or any actions or changes that would affect the Chief Quality
and Safety Officers ability to perform the duties necessary to meet the obligations in this
CIA, within five days after such a change.
4.
Quality, Safety, and Performance Improvement Department.
Parkland has appointed and shall continue to maintain a Quality, Safety, and
Performance Improvement Department comprised of the Chief Quality and Safety
Officer, senior officers (including the Chief Medical Officer and the VP of Quality and
Performance Improvement), and other clinical quality staff (including the Patient Safety
Officer). The Chief Quality and Safety Officer will chair the Quality, Safety, and
Performance Improvement Department. The Quality, Safety, and Performance
Improvement Department is responsible for monitoring: 1) clinical quality at Parkland,
2) the Quality, Safety, and Performance Improvement Program, 3) physician
credentialing, privileging, and peer review programs, 4) evidence-based medicine
programs, 5) standards of clinical excellence, 6) utilization management and review, and
7) other quality performance standards.
a.
ii.
iii.
b.
c.
management;
ii.
iii.
b.
c.
6.
Audit and Compliance Committee of the Board of Managers. The
Board has appointed a standing Audit and Compliance Committee. The Audit and
Compliance Committee is responsible for the review and oversight of matters related to
compliance with the requirements of Federal health care programs and the obligations of
this CIA. The Audit and Compliance Committee, and any successor Committee formed
by the Board shall ensure that Parkland is appropriately identifying, assessing, and
correcting compliance concerns and risks. The Audit and Compliance Committee shall,
at a minimum:
a.
b.
c.
e.
f.
7.
Quality of Care and Patient Safety Committee of the Board of
Managers. The Board has appointed a standing Quality of Care and Patient Safety
Committee. The Quality of Care and Patient Safety Committee is responsible for the
review and oversight of matters related to professionally recognized standards of care and
the obligations of this CIA. The Quality of Care and Patient Safety Committee shall
ensure that Parkland is appropriately identifying and correcting quality of care problems.
The Quality of Care and Patient Safety Committee shall, at a minimum:
a. Meet at least quarterly;
b. Review and oversee Parklands Quality, Safety, and
Performance Improvement Program, including but not limited
to the performance of the Chief Quality and Safety Officer and
the Quality, Safety, and Performance Improvement
Department;
c. Review and respond to the Dashboard to ensure that Parkland
implements effective responses when potential quality
problems are indicated on the Dashboard or when quality
indicators show that Parkland is not meeting its established
goals;
d. Within 90 days of the completion of the Survey, the Quality of
Care and Patient Safety Committee shall arrange for the
performance of a review of the effectiveness of Parklands
Quality, Safety, and Performance Improvement Program
(Quality Program Review) to cover each Reporting Period of
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Written Standards
1.
Code of Conduct. Parkland adopted a Code of Conduct and Ethics
(Code of Conduct). To the extent not already accomplished, within 90 days after the
Effective Date, Parkland shall revise, implement, and distribute the written Code of
Conduct to all Covered Persons. Parkland shall make the promotion of, and adherence
to, the Code of Conduct an element in evaluating the performance of all employees. The
Code of Conduct shall, at a minimum, set forth:
a.
b.
c.
d.
f.
Within 90 days after the promulgation of any revision to the Code of Conduct,
each Covered Person shall certify, in writing or in electronic form, that he or she has
received, read, understood, and shall abide by Parklands Code of Conduct. New
Covered Persons shall receive the Code of Conduct and shall complete the required
certification within 30 days after becoming a Covered Person or within 90 days after the
Effective Date, whichever is later.
Parkland shall periodically review the Code of Conduct to determine if revisions
are appropriate and shall make any necessary revisions based on such review. Any
revised Code of Conduct shall be distributed within 30 days after any revisions are
finalized and approved by the Board. Each Covered Person shall certify, in writing or
electronic form, that he or she has received, read, understood, and shall abide by the
revised Code of Conduct within 30 days after the distribution of the revised Code of
Conduct.
2.
Policies and Procedures. To the extent not already completed,
Parkland shall implement written Policies and Procedures regarding the operation of its
compliance program, including the compliance program requirements outlined in this
CIA, Providers compliance with Federal health care program requirements, and
addressing the following subject areas:
a.
10
b.
i.
ii.
iii.
iv.
v.
ii.
iii.
iv.
c.
v.
vi.
vii.
viii.
ix.
x.
xi.
xii.
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ii.
iii.
To the extent not already completed, within 90 days after the Effective Date, the
Billing and Reimbursement Policies and Procedures and the Performance Standards and
Incentives Policies and Procedures shall be distributed to all Covered Persons. To the
extent not already completed, within 90 days after the completion of the Survey, the
Clinical Quality Policies and Procedures shall be distributed to all Covered Persons.
Appropriate and knowledgeable staff shall be available to explain the Policies and
Procedures.
At least annually (and more frequently, if appropriate), Parkland shall assess and
update, as necessary, the Policies and Procedures. Within 30 days after the effective date
of any revisions, any such revised Policies and Procedures shall be distributed to all
Covered Persons.
C.
1.
General Training. Within 90 days after the Effective Date, Parkland
shall provide at least two hours of General Training to each Covered Person. This
training, at a minimum, shall explain Parklands:
a.
b.
New Covered Persons shall receive the General Training described above within
30 days after becoming a Covered Person or within 90 days after the Effective Date,
whichever is later. After receiving the initial General Training described above, each
Covered Person shall receive at least one hour of General Training in each subsequent
Reporting Period.
13
2.
Billing and Reimbursement Training. Within 90 days after the
Effective Date, each Billing and Reimbursement Covered Person shall receive at least
four hours of Billing and Reimbursement Training in addition to the General Training
required above. This Billing Reimbursement Training must include a discussion of the
following topics:
a.
b.
c.
d.
e.
f.
g.
New Billing and Reimbursement Covered Persons shall receive this training
within 30 days after the beginning of their employment or becoming Billing and
Reimbursement Covered Persons, or within 90 days after the Effective Date, whichever is
later.
After receiving the initial Billing and Reimbursement Training described in this
section, each Billing and Reimbursement Covered Person shall receive at least two hours
of Billing and Reimbursement Training, in addition to the General Training, in each
subsequent Reporting Period.
3.
Clinical Quality Training. Within 90 days after the completion of
the Survey, each Clinical Quality Covered Person shall receive at least four hours of
14
Clinical Quality Training in addition to the General Training required above. This
Clinical Quality Training must include a discussion of the following topics:
a.
b.
c.
d.
e.
New Clinical Quality Covered Persons shall receive this training within 30 days
after the beginning of their employment or becoming Clinical Quality Covered Persons,
or within 90 days after the completion of the Survey, whichever is later.
After receiving the initial Clinical Quality Training described in this section, each
Clinical Quality Covered Person shall receive at least two hours of Clinical Quality
Training, in addition to the General Training, in each subsequent Reporting Period.
4.
Board Member Training. Within 120 days after the Effective Date,
Parkland shall provide at least two hours of training to each member of the Board, in
addition to the General Training. This training shall address the responsibilities of Board
members and corporate governance. In November 2012, the Outside Expert provided the
Board with a report on the fiduciary duties of Board members, including their oversight
15
16
D.
Review Procedures
1.
b.
c.
2.
Retention of Records. The ROs and Parkland shall retain and make
available to OIG, upon request, all work papers, supporting documentation,
correspondence, and draft reports (those exchanged between the ROs and Parkland)
related to the reviews.
3.
Type of Reviews. The following reviews shall be performed by ROs
to be engaged and retained by Parkland during the term of the CIA: (a) Claims Review;
(b) Unallowable Costs Review; and (c) Clinical Quality Systems Review (collectively the
External Reviews). The requirements for the External Reviews are provided below and
in Appendices C and D to this CIA, which are hereby incorporated by reference into the
CIA.
4.
Claims Review. The Billing IRO shall review Parklands coding,
billing, and claims submission to the Federal health care programs and the reimbursement
received (Claims Review) and shall prepare a Claims Review Report, as outlined in
Appendix C to this CIA.
17
5.
Clinical Quality Systems Review. The QRO shall assess the
effectiveness, reliability, and thoroughness of Parklands quality of care and patient
safety systems, as outlined in Appendix D to this CIA.
6.
Unallowable Cost Review. For the first Reporting Period, the
Billing IRO shall conduct a review of Parklands compliance with the unallowable cost
provisions of the Settlement Agreement. The Billing IRO shall determine whether
Parkland has complied with its obligations not to charge to, or otherwise seek payment
from, Federal or State payors for unallowable costs (as defined in the Settlement
Agreement) and its obligation to identify to applicable Federal or State payors any
unallowable costs included in payments previously sought from the United States, or any
state Medicaid program. This unallowable costs analysis shall include, but not be limited
to, payments sought in any cost reports, cost statements, information reports, or payment
requests already submitted by Parkland or any affiliates. To the extent that such cost
reports, cost statements, information reports, or payment requests, even if already settled,
have been adjusted to account for the effect of the inclusion of the unallowable costs, the
Billing IRO shall determine if such adjustments were proper. In making this
determination, the Billing IRO may need to review cost reports and/or financial
statements from the year in which the Settlement Agreement was executed, as well as
from previous years.
7.
Unallowable Cost Review Report. The Billing IRO shall prepare a
report based upon the Unallowable Cost Review performed (Unallowable Cost Review
Report). The Unallowable Cost Review Report shall include the Billing IROs findings
and supporting rationale regarding the Unallowable Cost Review and whether Parkland
has complied with its obligation not to charge to, or otherwise seek payment from,
Federal or State payors for unallowable costs (as defined in the Settlement Agreement)
and its obligation to identify to applicable Federal or State payors any unallowable costs
included in payments previously sought from such payor.
8.
Validation Review. In the event OIG has reason to believe that:
(a) Parklands Claims Review or Unallowable Cost Review fails to conform to the
requirements of this CIA; or (b) the Billing IROs findings or Claims Review or
Unallowable Cost Review results are inaccurate, OIG may, at its sole discretion, conduct
its own review to determine whether the Claims Review or Unallowable Cost Review
complied with the requirements of the CIA and/or the findings or Claims Review or
Unallowable Cost Review results are inaccurate (Validation Review). Parkland shall pay
for the reasonable cost of any such review performed by OIG or any of its designated
agents. Any Validation Review of Reports submitted as part of Parklands final Annual
18
Report shall be initiated no later than one year after Parklands final submission (as
described in Section II) is received by OIG.
Prior to initiating a Validation Review, OIG shall notify Parkland of its intent to
do so and provide a written explanation of why OIG believes such a review is necessary.
To resolve any concerns raised by OIG, Parkland may request a meeting with OIG to:
(a) discuss the results of any Claims Review or Unallowable Cost Review submissions or
findings; (b) present any additional information to clarify the results of the Claims
Review or Unallowable Cost Review or to correct the inaccuracy of the Claims Review
or Unallowable Cost Review; and/or (c) propose alternatives to the proposed Validation
Review. Parkland agrees to provide any additional information as may be requested by
OIG under this Section III.D.6-7 in an expedited manner. OIG will attempt in good faith
to resolve any External Review issues with Parkland prior to conducting a Validation
Review. However, the final determination as to whether or not to proceed with a
Validation Review shall be made at the sole discretion of OIG.
9.
Independence and Objectivity Certification. The Billing IRO shall
include in its report(s) to Parkland a certification that the Billing IRO has: (a) evaluated
its professional independence and objectivity with respect to the reviews conducted under
this Section III.D and (b) concluded that it is, in fact, independent and objective, in
accordance with the requirements specified in Appendix A to this CIA.
E.
Disclosure Program
Parkland has established and shall continue to maintain a Disclosure Program that
includes a mechanism (e.g., a toll-free compliance telephone line) to enable individuals to
disclose, to the Compliance Officer or some other person who is not in the disclosing
individuals chain of command, any identified issues or questions associated with
Parklands policies, conduct, practices, or procedures with respect to a Federal health
care program believed by the individual to be a potential violation of criminal, civil, or
administrative law. Parkland shall appropriately publicize the existence of the disclosure
mechanism (e.g., via periodic e-mails to employees or by posting the information in
prominent common areas).
The Disclosure Program shall emphasize a nonretribution, nonretaliation policy,
and shall include a reporting mechanism for anonymous communications for which
appropriate confidentiality shall be maintained. Upon receipt of a disclosure, the
Compliance Officer (or designee) shall gather all relevant information from the
disclosing individual. The Compliance Officer (or designee) shall make a preliminary,
good faith inquiry into the allegations set forth in every disclosure to ensure that he or she
19
has obtained all of the information necessary to determine whether a further review
should be conducted. For any disclosure that is sufficiently specific so that it reasonably:
(1) permits a determination of the appropriateness of the alleged improper practice; and
(2) provides an opportunity for taking corrective action, Parkland shall conduct an
internal review of the allegations set forth in the disclosure and ensure that proper followup is conducted.
The Compliance Officer (or designee) shall maintain a disclosure log, which shall
include a record and summary of each disclosure received (whether anonymous or not),
the status of the respective internal reviews, and any corrective action taken in response
to the internal reviews.
F.
Ineligible Persons
1.
b.
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2.
Screening Requirements. Parkland shall ensure that all prospective
and current Covered Persons are not Ineligible Persons, by implementing the following
screening requirements.
a.
b.
c.
other practitioners medical staff privileges, Parkland shall take all appropriate actions to
ensure that the responsibilities of that Covered Person have not and shall not adversely
affect the quality of care rendered to any beneficiary, patient, or resident, or any claims
submitted to any Federal health care program.
G.
Within 30 days after discovery, Parkland shall notify OIG, in writing, of any
ongoing investigation or legal proceeding known to Parkland conducted or brought by a
governmental entity or its agents involving an allegation that Parkland has committed a
crime or has engaged in fraudulent activities. This notification shall include a description
of the allegation, the identity of the investigating or prosecuting agency, and the status of
such investigation or legal proceeding. Parkland shall also provide written notice to OIG
within 30 days after the resolution of the matter, and shall provide OIG with a description
of the findings and/or results of the investigation or proceedings, if any.
H.
Repayment of Overpayments
1.
Definition of Overpayments. For purposes of this CIA, an
Overpayment shall mean the amount of money Parkland has received in excess of the
amount due and payable under any Federal health care program requirements.
2.
Repayment of Overpayments
a.
22
b.
I.
Reportable Events
1.
Definition of Reportable Event. For purposes of this CIA, a
Reportable Event means anything that involves:
a.
a substantial Overpayment;
b.
c.
d.
b.
23
c.
d.
e.
4.
Reportable Events under Section III.I.1.b and c. For Reportable
Events under Section III.I.1.b and III.I.1.c, the report to OIG shall include:
a.
b.
c.
d.
5.
Reportable Events under Section III.I.1.d. For Reportable Events
under Section III.I.1.d, the report to OIG shall include:
a.
b.
c.
6.
Reportable Events Involving the Stark Law. Notwithstanding the
reporting requirements outlined above, any Reportable Event that involves only a
probable violation of section 1877 of the Social Security Act, 42 U.S.C. 1395nn (the
24
Stark Law) should be submitted by Parkland to the Centers for Medicare & Medicaid
Services (CMS) through the self-referral disclosure protocol (SRDP), with a copy to the
OIG. The requirements of Section III.H.2 that require repayment to the payor of any
identified Overpayment within 30 days shall not apply to any Overpayment that may
result from a probable violation of only the Stark Law that is disclosed to CMS pursuant
to the SRDP.
IV.
In the event that, after the Effective Date, Parkland changes locations or closes a
business unit or location related to the furnishing of items or services that may be
reimbursed by Federal health care programs, Parkland shall notify OIG of this fact as
soon as possible, but no later than within 30 days after the date of change or closure of
the location.
B.
In the event that, after the Effective Date, Parkland purchases or establishes a new
business unit or location related to the furnishing of items or services that may be
reimbursed by Federal health care programs, Parkland shall notify OIG at least 30 days
prior to such purchase or the operation of the new business unit or location. This
notification shall include the address of the new business unit or location, phone number,
fax number, the locations Medicare and state Medicaid program provider number and/or
supplier number(s); and the name and address of each Medicare and state Medicaid
program contractor to which Parkland currently submits claims. Each new business unit
or location and all Covered Persons at each new business unit or location shall be subject
to the applicable requirements of this CIA.
C.
In the event that, after the Effective Date, Parkland proposes to sell any or all of its
business units or locations that are subject to this CIA, Parkland shall notify OIG of the
proposed sale at least 30 days prior to the sale of such business unit or location. This
notification shall include a description of the business unit or location to be sold, a brief
description of the terms of the sale, and the name and contact information of the
prospective purchaser. This CIA shall be binding on the purchaser of such business unit
or location, unless otherwise determined and agreed to in writing by the OIG.
25
V.
Implementation Report
Within 90 days after the completion of the Survey, Parkland shall submit a written
report to OIG summarizing the status of its implementation of the requirements of this
CIA (Implementation Report). The Implementation Report shall include, at a minimum:
1.
the name, address, phone number, and position description of the
Compliance Officer required by Section III.A.1, and a summary of other noncompliance
job responsibilities the Compliance Officer may have;
2.
the names and positions of the members of the Compliance
Committee required by Section III.A.2;
3.
the name, address, phone number, and position description of the
Chief Quality and Safety Officer required by Section III.A.3, and a summary of other
non-quality assurance job responsibilities the Chief Quality and Safety Officer may have;
4.
the names and positions of the members of the Quality, Safety, and
Performance Improvement Department required by Section III.A.4;
5.
the names and qualifications of the members of the Audit and
Compliance Committee required by Section III.A.6.;
6.
the names and qualifications of the members of the Quality of Care
and Patient Safety Committee required by Section III.A.7.;
7.
the name, address, phone number, and qualifications of the Outside
Expert to the Board required by Section III.A.5;
8.
a description of the Quality, Safety, and Performance Improvement
Program required by Section III.A.4.a;
9.
a description of the 1) quality improvement goals, 2) quality
indicators, and 3) performance metrics identified in the design of Quality of Care
Dashboard pursuant to Section III.A.4.b;
10.
26
11.
the number of individuals required to complete the Code of Conduct
certification required by Section III.B.1, the percentage of individuals who have
completed such certification, and an explanation of any exceptions (the documentation
supporting this information shall be available to OIG upon request);
12.
a summary of all Policies and Procedures required by Section III.B.2
(copies of the Policies and Procedures shall be made available to OIG upon request);
13.
by Section III.C:
b.
c.
A copy of all training materials and the documentation supporting this information shall
be made available to OIG upon request.
14.
15.
the following information regarding the Billing IRO(s): (a) identity,
address, and phone number; (b) a copy of the engagement letter; (c) information to
demonstrate that the Billing IRO has the qualifications outlined in Appendix A to this
CIA; (d) a summary and description of any and all current and prior engagements and
agreements between Parkland and the Billing IRO; and (e) a certification from the Billing
IRO regarding its professional independence and objectivity with respect to Parkland;
16.
a description of the process by which Parkland fulfills the
requirements of Section III.F regarding Ineligible Persons;
17.
a list of all of Parklands locations (including locations and mailing
addresses); the corresponding name under which each location is doing business; the
27
corresponding phone numbers and fax numbers; each locations Medicare and state
Medicaid program provider number and/or supplier number(s); and the name and address
of each Medicare and state Medicaid program contractor to which Parkland currently
submits claims;
18.
a description of Parklands corporate structure, including
identification of any parent and sister companies, subsidiaries, and their respective lines
of business; and
19.
B.
Annual Reports
Parkland shall submit to OIG annually a report with respect to the status of, and
findings regarding, Parklands compliance and quality assurance activities for each of the
five Reporting Periods (Annual Report). Each Annual Report shall include, at a
minimum:
1.
any change in the identity, position description, or other
noncompliance or non-quality assurance job responsibilities of the Compliance Officer or
Chief Quality and Safety Officer;
2.
any change in the membership of the Compliance Committee,
Quality, Safety, and Performance Improvement Department, Audit and Compliance
Committee, or Quality of Care and Patient Safety Committee described in Section III.A;
3.
4.
III.A.5;
5.
a summary of any changes or amendments to Parklands Quality,
Safety, and Performance Improvement Program required by Section III.A.4.a, and the
reason for such changes;
6.
a summary of any changes or amendments to Parklands Code of
Conduct required by Section III.B.1 and the reason for such changes, along with a copy
of the revised Code of Conduct;
7.
the number of individuals required to complete the Code of Conduct
certification required by Section III.B.1, the percentage of individuals who have
28
b.
c.
A copy of all training materials and the documentation to support this information shall
be made available to OIG upon request.
10.
A description of all internal audits or reviews performed as a part of
the Quality, Safety, and Performance Improvement Program prepared pursuant to Section
III.A.4.a, any corrective action taken in response to any problems identified through
these audits or reviews, and any changes to the audit and review process;
11.
A description of the Quality, Safety, and Performance Improvement
Departments measurement, analysis, and tracking of the performance metrics included in
Parklands Dashboard, Parklands progress towards its quality improvement goals, and
any changes to the Dashboard and the reasons for such changes;
12.
a complete copy of the Compliance Program Review Report and
Quality Program Review Report prepared pursuant to Section III.A.6;
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13.
a complete copy of all reports prepared pursuant to Section III.D,
along with a copy of each ROs engagement letter;
14.
Parklands response to the reports prepared pursuant to Section
III.D, along with corrective action plan(s) related to any issues raised by the reports;
15.
a summary and description of any and all current and prior
engagements and agreements between Parkland and the Billing IRO (if different from
what was submitted as part of the Implementation Report);
16.
a certification from the Billing IRO regarding its professional
independence and objectivity with respect to Parkland;
17.
a summary of Reportable Events (as defined in Section III.I)
identified during the Reporting Period and the status of any corrective action relating to
all such Reportable Events;
18.
a log of all Reportable Quality Events that have been submitted to
the QRO, pursuant Appendix D, Section B, during the reporting period. The log must
indicate:
a.
b.
19.
a report of the aggregate Overpayments that have been returned to
the Federal health care programs. Overpayment amounts shall be broken down into the
following categories: inpatient Medicare, outpatient Medicare, Medicaid (report each
applicable state separately, if applicable), and other Federal health care programs.
Overpayment amounts that are routinely reconciled or adjusted pursuant to Policies and
Procedures established by the payor do not need to be included in this aggregate
Overpayment report;
20.
a summary of the disclosures in the disclosure log required by
Section III.E that relate to Federal health care programs (the complete disclosure log shall
be made available to OIG upon request);
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21.
any changes to the process by which Parkland fulfills the
requirements of Section III.F regarding Ineligible Persons;
22.
a summary describing any ongoing investigation or legal proceeding
required to have been reported pursuant to Section III.G. The summary shall include a
description of the allegation, the identity of the investigating or prosecuting agency, and
the status of such investigation or legal proceeding;
23.
a description of all changes to the most recently provided list of
Parklands locations (including addresses) as required by Section V.A.16; the
corresponding name under which each location is doing business; the corresponding
phone numbers and fax numbers; each locations Medicare and state Medicaid program
provider number(s) and/or supplier number(s); and the name and address of each
Medicare and state Medicaid program contractor to which Parkland currently submits
claims; and
24.
The first Annual Report shall be received by OIG no later than 60 days after the
end of the first Reporting Period. Subsequent Annual Reports shall be received by OIG
no later than the anniversary date of the due date of the first Annual Report.
C.
Certifications
1.
The Implementation Report and each Annual Report shall include a
certification by the Compliance Officer that:
a.
b.
c.
D.
a.
b.
Designation of Information
Parkland shall clearly identify any portions of its submissions that it believes are
trade secrets, or information that is commercial or financial and privileged or
confidential, and therefore potentially exempt from disclosure under the Freedom of
Information Act (FOIA), 5 U.S.C. 552. Parkland shall refrain from identifying any
information as exempt from disclosure if that information does not meet the criteria for
exemption from disclosure under FOIA.
E.
1.
Parkland shall submit to OIG any report or written recommendations
produced by the Independent Consultative Expert pursuant to the Systems Improvement
Agreement within five days of Parkland receiving any report or written recommendations
from the Independent Consultative Expert.
2.
Parkland shall submit to OIG any report Parkland provides to the
Independent Consultative Expert pursuant to the Systems Improvement Agreement at the
same time Parkland provides the report to the Monitor.
3.
Any written documentation Parkland provides to the Independent
Consultative Expert pursuant to the Systems Improvement Agreement shall be made
available to the OIG upon request.
32
VI.
Unless otherwise stated in writing after the Effective Date, all notifications and
reports required under this CIA shall be submitted to the following entities:
OIG:
Administrative and Civil Remedies Branch
Office of Counsel to the Inspector General
Office of Inspector General
U.S. Department of Health and Human Services
Cohen Building, Room 5527
330 Independence Avenue, S.W.
Washington, DC 20201
Telephone: 202.619.2078
Facsimile: 202.205.0604
Parkland:
Mary S. Findley, MS, CPA, CHC
Sr. Vice President/Chief Compliance Officer
Parkland Health and Hospital System
5201 Harry Hines Blvd.
Dallas, TX 75235
Telephone: 214.590.2156
Unless otherwise specified, all notifications and reports required by this CIA may
be made by certified mail, overnight mail, hand delivery, or other means, provided that
there is proof that such notification was received. For purposes of this requirement,
internal facsimile confirmation sheets do not constitute proof of receipt. Upon request by
OIG, Parkland may be required to provide OIG with an electronic copy of each
notification or report required by this CIA in searchable portable document format (pdf),
in addition to a paper copy.
VII.
In addition to any other rights OIG may have by statute, regulation, or contract,
OIG or its duly authorized representative(s) may examine or request copies of Parklands
books, records, and other documents and supporting materials and/or conduct on-site
reviews of any of Parklands locations for the purpose of verifying and evaluating: (a)
Parklands compliance with the terms of this CIA; and (b) Parklands compliance with
the requirements of the Federal health care programs. The documentation described
33
above shall be made available by Parkland to OIG or its duly authorized representative(s)
at all reasonable times for inspection, audit, or reproduction. Furthermore, for purposes
of this provision, OIG or its duly authorized representative(s) may interview any of
Parklands employees, contractors, or agents who consent to be interviewed at the
individuals place of business during normal business hours or at such other place and
time as may be mutually agreed upon between the individual and OIG. Parkland shall
assist OIG or its duly authorized representative(s) in contacting and arranging interviews
with such individuals upon OIGs request. Parklands employees may elect to be
interviewed with or without a representative of Parkland present.
VIII. DOCUMENT AND RECORD RETENTION
Parkland shall maintain for inspection all documents and records relating to
reimbursement from the Federal health care programs and to compliance with this CIA
for six years (or longer if otherwise required by law) from the Effective Date.
IX.
DISCLOSURES
Consistent with HHSs FOIA procedures, set forth in 45 C.F.R. Part 5, OIG shall
make a reasonable effort to notify Parkland prior to any release by OIG of information
submitted by Parkland pursuant to its obligations under this CIA and identified upon
submission by Parkland as trade secrets, or information that is commercial or financial
and privileged or confidential, under the FOIA rules. With respect to such releases,
Parkland shall have the rights set forth at 45 C.F.R. 5.65(d).
X.
A.
Specific Performance of CIA Provisions. If OIG determines that Parkland
is failing to comply with a provision or provisions of this CIA and decides to seek
specific performance of any of these provisions, OIG shall provide Parkland with prompt
written notification of such determination. (This notification shall be referred to as the
Noncompliance Notice.) Parkland shall have 35 days from receipt of the
Noncompliance Notice within which to either: (1) cure the alleged failure to comply; or
(2) reply in writing that Parkland disagrees with the determination of noncompliance and
request a hearing before an HHS Administrative Law Judge (ALJ), pursuant to the
provisions set for in Section X.F of this CIA.
B.
Stipulated Penalties for Failure to Comply with Certain Obligations. As a
contractual remedy, Parkland and OIG hereby agree that failure to comply with certain
34
obligations as set forth in this CIA may lead to the imposition of the following monetary
penalties (hereinafter referred to as Stipulated Penalties) in accordance with the
following provisions.
1.
A Stipulated Penalty of $2,500 (which shall begin to accrue on the
day after the date the obligation became due) for each day Parkland fails to establish and
implement any of the following obligations as described in Section III:
a.
a Compliance Officer;
b.
a Compliance Committee;
c.
d.
e.
f.
g.
h.
i.
j.
k.
a Disclosure Program;
l.
m.
n.
2.
A Stipulated Penalty of $2,500 (which shall begin to accrue on the
day after the date the obligation became due) for each day Parkland fails to engage and
use a Billing IRO, as required in Section III.D and Appendices A and C.
3.
A Stipulated Penalty of $2,500 (which shall begin to accrue on the
day after the date the obligation became due) for each day Parkland fails to engage, use,
pay, or provide information and access to a QRO, as required in Section III.D and
Appendices B and D.
4.
A Stipulated Penalty of $2,500 (which shall begin to accrue on the
day after the date the obligation became due) for each day Parkland fails to submit the
Implementation Report or any Annual Reports to OIG in accordance with the
requirements of Section V by the deadlines for submission.
5.
A Stipulated Penalty of $2,500 (which shall begin to accrue on the
day after the date the obligation became due) for each day Parkland fails to submit any
External Review Report in accordance with the requirements of Section III.D,
Appendices C and D.
6.
A Stipulated Penalty of $1,500 for each day Parkland fails to grant
access as required in Section VII. (This Stipulated Penalty shall begin to accrue on the
date Parkland fails to grant access.)
7.
A Stipulated Penalty of $5,000 for each false certification submitted
by or on behalf of Parkland as part of its Implementation Report, Annual Report,
additional documentation to a report (as requested by the OIG), or otherwise required by
this CIA.
8.
A Stipulated Penalty of $2,500 (which shall begin to accrue on the
day after the date the obligation became due) for each day Parkland fails to submit its
response to the reports prepared pursuant to Section III.D, along with corrective action
plan(s) related to any issues raised by the reports, in accordance with the requirements of
Section V.B.14.
9.
A Stipulated Penalty of $1,000 for each day Parkland fails to comply
fully and adequately with any obligation of this CIA. OIG shall provide notice to
Parkland stating the specific grounds for its determination that Parkland has failed to
comply fully and adequately with the CIA obligation(s) at issue and steps Parkland shall
take to comply with the CIA. (This Stipulated Penalty shall begin to accrue 10 days after
Parkland receives this notice from OIG of the failure to comply.) A Stipulated Penalty as
36
described in this Subsection shall not be demanded for any violation for which OIG has
sought a Stipulated Penalty under Subsections 1- 8 of this Section.
C.
Timely Written Requests for Extensions. Parkland may, in advance of the
due date, submit a timely written request for an extension of time to perform any act or
file any notification or report required by this CIA. Notwithstanding any other provision
in this Section, if OIG grants the timely written request with respect to an act,
notification, or report, Stipulated Penalties for failure to perform the act or file the
notification or report shall not begin to accrue until one day after Parkland fails to meet
the revised deadline set by OIG. Notwithstanding any other provision in this Section, if
OIG denies such a timely written request, Stipulated Penalties for failure to perform the
act or file the notification or report shall not begin to accrue until three business days
after Parkland receives OIGs written denial of such request or the original due date,
whichever is later. A timely written request is defined as a request in writing received
by OIG at least five business days prior to the date by which any act is due to be
performed or any notification or report is due to be filed.
D.
1.
Demand Letter. Upon a finding that Parkland has failed to comply
with any of the obligations described in Section X.B and after determining that Stipulated
Penalties are appropriate, OIG shall notify Parkland of: (a) Parklands failure to comply;
and (b) OIGs exercise of its contractual right to demand payment of the Stipulated
Penalties. (This notification shall be referred to as the Demand Letter.)
2.
Response to Demand Letter. Within 10 days after the receipt of the
Demand Letter, Parkland shall either: (a) cure the breach to OIGs satisfaction and pay
the applicable Stipulated Penalties or (b) request a hearing before an HHS administrative
law judge (ALJ) to dispute OIGs determination of noncompliance, pursuant to the
agreed upon provisions set forth below in Section X.F. In the event Parkland elects to
request an ALJ hearing, the Stipulated Penalties shall continue to accrue until Parkland
cures, to OIGs satisfaction, the alleged breach in dispute. Failure to respond to the
Demand Letter in one of these two manners within the allowed time period shall be
considered a material breach of this CIA and shall be grounds for exclusion under Section
X.E.
3.
Form of Payment. Payment of the Stipulated Penalties shall be
made by electronic funds transfer to an account specified by OIG in the Demand Letter.
37
4.
Independence from Material Breach Determination. Except as set
forth in Section X.E.1.c, these provisions for payment of Stipulated Penalties shall not
affect or otherwise set a standard for OIGs decision that Parkland has materially
breached this CIA, which decision shall be made at OIGs discretion and shall be
governed by the provisions in Section X.E, below.
E.
means:
a.
b.
c.
d.
e.
f.
g.
2.
Notice of Material Breach and Intent to Exclude. The parties agree
that a material breach of this CIA by Parkland constitutes an independent basis for
Parklands exclusion from participation in the Federal health care programs. Upon a
determination by OIG that Parkland has materially breached this CIA and that exclusion
is the appropriate remedy, OIG shall notify Parkland of: (a) Parklands material breach;
38
and (b) OIGs intent to exercise its contractual right to impose exclusion. (This
notification shall be referred to as the Notice of Material Breach and Intent to Exclude.)
3.
Opportunity to Cure. Parkland shall have 30 days from the date of
receipt of the Notice of Material Breach and Intent to Exclude to demonstrate to OIGs
satisfaction that:
a.
b.
c.
4.
Exclusion Letter. If, at the conclusion of the 30 day period, Parkland
fails to satisfy the requirements of Section X.E.3, OIG may exclude Parkland from
participation in the Federal health care programs. OIG shall notify Parkland in writing of
its determination to exclude Parkland. (This letter shall be referred to as the Exclusion
Letter.) Subject to the Dispute Resolution provisions in Section X.F, below, the
exclusion shall go into effect 30 days after the date of Parklands receipt of the Exclusion
Letter. The exclusion shall have national effect. Reinstatement to program participation
is not automatic. After the end of the period of exclusion, Parkland may apply for
reinstatement by submitting a written request for reinstatement in accordance with the
provisions at 42 C.F.R. 1001.3001-.3004.
F.
Dispute Resolution
1.
Review Rights. Upon OIGs delivery to Parkland of its Demand
Letter or of its Exclusion Letter, and as an agreed-upon contractual remedy for the
resolution of disputes arising under this CIA, Parkland shall be afforded certain review
rights comparable to the ones that are provided in 42 U.S.C. 1320a-7(f) and 42 C.F.R.
Part 1005 as if they applied to the Stipulated Penalties or exclusion sought pursuant to
this CIA. Specifically, OIGs determination to demand payment of Stipulated Penalties
or to seek exclusion shall be subject to review by an HHS ALJ and, in the event of an
appeal, the HHS Departmental Appeals Board (DAB), in a manner consistent with the
provisions in 42 C.F.R. 1005.2-1005.21. Notwithstanding the language in 42 C.F.R.
39
1005.2(c), the request for a hearing involving Stipulated Penalties shall be made within
10 days after receipt of the Demand Letter and the request for a hearing involving
exclusion shall be made within 25 days after receipt of the Exclusion Letter.
2.
Stipulated Penalties Review. Notwithstanding any provision of Title
42 of the United States Code or Title 42 of the Code of Federal Regulations, the only
issues in a proceeding for Stipulated Penalties under this CIA shall be: (a) whether
Parkland was in full and timely compliance with the obligations of this CIA for which
OIG demands payment; and (b) the period of noncompliance. Parkland shall have the
burden of proving its full and timely compliance and the steps taken to cure the
noncompliance, if any. OIG shall not have the right to appeal to the DAB an adverse
ALJ decision related to Stipulated Penalties. If the ALJ agrees with OIG with regard to a
finding of a breach of this CIA and orders Parkland to pay Stipulated Penalties, such
Stipulated Penalties shall become due and payable 20 days after the ALJ issues such a
decision unless Parkland requests review of the ALJ decision by the DAB. If the ALJ
decision is properly appealed to the DAB and the DAB upholds the determination of
OIG, the Stipulated Penalties shall become due and payable 20 days after the DAB issues
its decision.
3.
Exclusion Review. Notwithstanding any provision of Title 42 of the
United States Code or Title 42 of the Code of Federal Regulations, the only issues in a
proceeding for exclusion based on a material breach of this CIA shall be:
a.
b.
c.
For purposes of the exclusion herein, exclusion shall take effect only after an ALJ
decision favorable to OIG, or, if the ALJ rules for Parkland, only after a DAB decision in
favor of OIG. Parklands election of its contractual right to appeal to the DAB shall not
abrogate OIGs authority to exclude Parkland upon the issuance of an ALJs decision in
40
favor of OIG. If the ALJ sustains the determination of OIG and determines that
exclusion is authorized, such exclusion shall take effect 20 days after the ALJ issues such
a decision, notwithstanding that Parkland may request review of the ALJ decision by the
DAB. If the DAB finds in favor of OIG after an ALJ decision adverse to OIG, the
exclusion shall take effect 20 days after the DAB decision. Parkland shall waive its right
to any notice of such an exclusion if a decision upholding the exclusion is rendered by the
ALJ or DAB. If the DAB finds in favor of Parkland, Parkland shall be reinstated
effective on the date of the original exclusion.
4.
Finality of Decision. The review by an ALJ or DAB provided for
above shall not be considered to be an appeal right arising under any statutes or
regulations. Consequently, the parties to this CIA agree that the DABs decision (or the
ALJs decision if not appealed) shall be considered final for all purposes under this CIA.
XI.
B.
This CIA shall become final and binding on the date the final signature is
obtained on the CIA.
C.
This CIA constitutes the complete agreement between the parties and may
not be amended except by written consent of the parties to this CIA.
D.
E.
The undersigned Parkland signatories represent and warrant that they are
authorized to execute this CIA. The undersigned OIG signatory represents
41
that he is signing this CIA in his official capacity and that he is authorized
to execute this CIA.
F.
42
ON BEHALF OF PARKLAND
/Robert L. Smith/
5/24/13
ROBERT L. SMITH
Interim Chief Executive Officer
Parkland Health and Hospital System
DATE
/Mary S. Findley/
5/24/13
5/24/13
PAUL S. LESLIE
General Counsel
Parkland Health and Hospital System
DATE
/Roger S. Goldman/
5/28/13
ROGER S. GOLDMAN
Latham and Watkins, LLP
Counsel for Parkland
DATE
43
/Robert K. DeConti/
5/30/13
ROBERT K. DECONTI
Assistant Inspector General for Legal Affairs
Office of Inspector General
U. S. Department of Health and Human Services
DATE
5/28/13
DATE
/Katherine Matos/
5/28/13
KATHERINE MATOS
Associate Counsel
Office of Inspector General
U. S. Department of Health and Human Services
DATE
44
APPENDIX A
BILLING INDEPENDENT REVIEW ORGANIZATION
A.
1.
Parkland shall engage a Billing IRO that possesses the qualifications
set forth in Paragraph B, below, to perform the responsibilities in Paragraph C, below.
The Billing IRO shall conduct the review in a professionally independent and objective
fashion, as set forth in Paragraph D. Within 30 days after OIG receives the information
identified in Section V.A.14 of the CIA or any additional information submitted by
Parkland in response to a request by OIG, whichever is later, OIG will notify Parkland if
the IRO is unacceptable. Absent notification from OIG that the Billing IRO is
unacceptable, Parkland may continue to engage the Billing IRO.
2.
If Parkland engages a new Billing IRO during the term of the CIA,
this IRO shall also meet the requirements of this Appendix. If a new Billing IRO is
engaged, Parkland shall submit the information identified in Section V.A.14 of the CIA
to OIG within 30 days of engagement of the IRO. Within 30 days after OIG receives this
information or any additional information submitted by Parkland at the request of OIG,
whichever is later, OIG will notify Parkland if the IRO is unacceptable. Absent
notification from OIG that the Billing IRO is unacceptable, Parkland may continue to
engage the IRO.
B.
45
4.
have sufficient staff and resources to conduct the reviews required
by the CIA on a timely basis.
C.
manner; and
5.
prepare timely, clear, well-written reports that include all the
information required by Appendix C to the CIA.
D.
The IRO must perform the Claims Review in a professionally independent and
objective fashion, as defined in the most recent Government Auditing Standards issued
by the United States Government Accountability Office.
E.
1.
Parkland and Billing IRO. If Parkland terminates its Billing IRO
engaged under Paragraph A.1 of this Appendix or if the Billing IRO withdraws from the
engagement during the term of the CIA, Parkland must submit a notice explaining its
reasons for termination or the reason for withdrawal to OIG no later than 30 days after
termination or withdrawal. Parkland must engage a new Billing IRO in accordance with
Paragraph A of this Appendix and within 60 days of termination or withdrawal of the
Billing IRO.
46
2.
OIG Removal of Billing IRO. In the event OIG has reason to believe
the Billing IRO does not possess the qualifications described in Paragraph B, is not
independent and objective as set forth in Paragraph D, or has failed to carry out its
responsibilities as described in Paragraph C, OIG may, at its sole discretion, require
Parkland to engage a new Billing IRO in accordance with Paragraph A.1 of this
Appendix. Parkland must engage a new Billing IRO within 60 days of termination of the
Billing IRO.
Prior to requiring Parkland to engage a new Billing IRO, OIG shall notify
Parkland of its intent to do so and provide a written explanation of why OIG believes
such a step is necessary. To resolve any concerns raised by OIG, Parkland may present
additional information regarding the Billing IROs qualifications, independence or
performance of its responsibilities. OIG will attempt in good faith to resolve any
differences regarding the Billing IRO with Parkland prior to requiring Parkland to
terminate the Billing IRO. However, the final determination as to whether or not to
require Parkland to engage a new Billing IRO shall be made at the sole discretion of OIG.
47
APPENDIX B
QUALITY REVIEW ORGANIZATION
A.
1.
Within 60 days after the Effective Date, Parkland shall retain an
appropriately qualified monitoring team, the QRO, selected by OIG after consultation
with Parkland. The QRO may retain additional personnel, including but not limited to
independent consultants, if needed to help meet the QROs obligations under this CIA.
The QRO may confer and correspond with Parkland or OIG individually or together.
The QRO and Parkland shall not negotiate or enter into a financial relationship, other
than the monitoring engagement required by this section, until after the date of OIGs
CIA closure letter to Parkland or six months after the expiration of this CIA, whichever is
later.
2.
The QRO is not an agent of OIG. However, the QRO may be
removed by OIG at its sole discretion. If the QRO resigns or is removed for any other
reasons prior to the termination of the CIA, Parkland shall retain, within 60 days of the
resignation or removal, another QRO selected by OIG after consultation with Parkland,
with the same functions and authorities.
B.
QRO Responsibilities
manner; and
4.
prepare timely, clear, well-written reports that include all the
information required by Appendix D to the CIA.
C.
QRO Qualifications. The QROs employees shall have expertise in
evaluating clinical quality management in the acute care setting.
48
D.
1.
Parkland shall be responsible for all reasonable costs incurred by the
QRO in connection with this engagement, including but not limited to labor costs (direct
and indirect); consultant and subcontract costs; materials cost (direct and indirect); and
other direct costs (travel, other miscellaneous).
2.
Parkland shall pay the QROs bills within 30 days of receipt, unless
otherwise negotiated with the QRO. Failure to pay the QRO within 30 calendar days of
submission of the QROs invoice for services previously rendered shall constitute a basis
to impose stipulated penalties or exclude Parkland, as provided under Section X.3 of the
CIA. While Parkland must pay all of the QROs bills within 30 days, Parkland may bring
any disputed QROs Costs or bills to OIGs attention.
3.
The QRO shall charge a reasonable amount for its fees and
expenses. The QRO shall submit a written report for each Reporting Period representing
an accounting of its costs throughout the year to Parkland and to OIG by the submission
deadline of Parklands Annual Report.
E.
Within 60 days after a QRO is retained by Parkland or 120 days after the Effective Date
of the CIA, whichever is later, Parkland shall provide the QRO with all reports issued by
the ICE in connection with the SIA.
49
APPENDIX C
CLAIMS REVIEW
A.
Claims Review. The Billing IRO shall perform the Claims Review
annually to cover each of the five Reporting Periods. The Billing IRO shall perform all
components of each Claims Review.
1.
Definitions. For the purposes of the Claims Review, the following
definitions shall be used:
a.
b.
c.
Population:
i.
ii.
50
2.
Discovery Sample. The Billing IRO shall randomly select and
review a sample of 200 Paid Claims (Discovery Sample) each Reporting Period. The
Paid Claims reviewed shall be comprised of four strata (Strata) as follows: 50 Medicare
inpatient Paid Claims, 50 Medicare outpatient Paid Claims, 50 Medicaid inpatient Paid
Claims, and 50 Medicaid outpatient Paid Claims. Each Strata shall be reviewed
separately. The Paid Claims shall be reviewed based on the supporting documentation
available at Parklands office or under Parklands control and applicable billing and
coding regulations and guidance to determine whether the claim was correctly coded,
submitted, and reimbursed.
If the Error Rate (as defined above) for any Strata of the Discovery Sample is less
than 5%, no additional sampling for that Strata is required, nor is the Systems Review
required. (Note: The guidelines listed above do not imply that this is an acceptable error
rate. Accordingly, Parkland should, as appropriate, further analyze any errors identified
in the Discovery Sample. Parkland recognizes that OIG or other HHS component, in its
discretion and as authorized by statute, regulation, or other appropriate authority may also
analyze or review Paid Claims included, or errors identified, in the Discovery Sample or
any other segment of the universe.)
3.
Full Sample. If the Discovery Sample indicates that the Error Rate
for any Strata is 5% or greater, the Billing IRO shall select an additional sample of Paid
Claims (Full Sample) in that Strata using commonly accepted sampling methods. The
Full Sample shall be designed to: (1) estimate the actual Overpayment in the population
51
with a 90% confidence level and with a maximum relative precision of 25% of the point
estimate; and (2) conform with the Centers for Medicare and Medicaid Services
statistical sampling for overpayment estimation guidelines. The Paid Claims selected for
the Full Sample shall be reviewed based on supporting documentation available at
Parkland or under Parklands control and applicable billing and coding regulations and
guidance to determine whether the claim was correctly coded, submitted, and reimbursed.
For purposes of calculating the size of the Full Sample, the Discovery Sample may serve
as the probe sample, if statistically appropriate. Additionally, the Billing IRO may use
the Paid Claims sampled as part of the Discovery Sample, and the corresponding findings
for those Paid Claims, as part of its Full Sample, if: (1) statistically appropriate and (2)
the Billing IRO selects the Full Sample Paid Claims using the seed number generated by
the Discovery Sample. OIG, in its sole discretion, may refer the findings of the Full
Sample (and any related work papers) received from Parkland to the appropriate Federal
health care program payor, including the Medicare contractor (e.g., carrier, fiscal
intermediary, or DMERC), for appropriate follow-up by that payor.
4.
Systems Review. If Parklands Discovery Sample identifies an Error
Rate of 5% or greater in any Strata, Parklands Billing IRO shall also conduct a Systems
Review. The Systems Review shall consist of the following:
a.
b.
for each claim in the Discovery Sample and Full Sample that
resulted in an Overpayment, the Billing IRO shall review the
system(s) and process(es) that generated the claim and
identify any problems or weaknesses that may have resulted
in the identified Overpayments. The Billing IRO shall
provide its observations and recommendations on suggested
improvements to the system(s) and the process(es) that
generated the claim.
52
5.
Other Requirements
a.
b.
c.
6.
Repayment of Identified Overpayments. Parkland shall repay within
30 days any Overpayment(s) identified in the Discovery Sample or the Full Sample (if
applicable), regardless of the Error Rate, to the appropriate payor and in accordance with
53
payor refund policies. Parkland shall make available to OIG all documentation that
reflects the refund of the Overpayment(s) to the payor.
B.
Claims Review Report. The Billing IRO shall prepare a Claims Review
Report as described in this Appendix for each Claims Review performed. The following
information shall be included in the Claims Review Report for each Discovery Sample
and Full Sample (if applicable).
1.
2.
b.
c.
d.
e.
b.
c.
3.
Narrative Results
i.
A description of Parklands billing and coding
system(s), including the identification, by position
description, of the personnel involved in coding and billing.
ii.
A narrative explanation of the Billing IROs findings
and supporting rationale (including reasons for errors,
patterns noted, etc.) regarding the Claims Review, including
the results of the Discovery Sample, and the results of the
Full Sample (if any).
b.
Quantitative Results
i.
Total number and percentage of instances in which the
Billing IRO determined that the Paid Claims submitted by
Parkland (Claim Submitted) differed from what should have
been the correct claim (Correct Claim), regardless of the
effect on the payment.
ii.
Total number and percentage of instances in which the
Claim Submitted differed from the Correct Claim and in
which such difference resulted in an Overpayment to
Parkland.
iii.
Total dollar amount of all Overpayments in the
sample.
iv.
Total dollar amount of Paid Claims included in the
sample and the net Overpayment associated with the sample.
v.
55
Corporate Integrity Agreement
Dallas County Hospital District d/b/a Parkland Health and Hospital System
vi.
A spreadsheet of the Claims Review results that
includes the following information for each Paid Claim:
Federal health care program billed, beneficiary health
insurance claim number, date of service, code submitted (e.g.,
DRG, CPT code, etc.), code reimbursed, allowed amount
reimbursed by payor, correct code (as determined by the
Billing IRO), correct allowed amount (as determined by the
Billing IRO), dollar difference between allowed amount
reimbursed by payor and the correct allowed amount.
c.
4.
Systems Review Findings. The Billing IRO shall prepare a Systems
Review Report based on the Systems Review performed (if applicable) that shall include
the Billing IROs observations, findings, and recommendations regarding:
a.
b.
c.
5.
Credentials. The names and credentials of the individuals who: (1)
designed the statistical sampling procedures and the review methodology utilized for the
Claims Review and (2) performed the Claims Review.
56
APPENDIX D
CLINICAL QUALITY SYSTEMS REVIEW
The QRO shall perform a Clinical Quality Systems Review annually to cover each
of the five Reporting Periods. The QRO shall perform all components of each Clinical
Quality Systems Review.
A.
The QRO shall perform a Clinical Quality Systems Review to assess the
effectiveness, reliability, and thoroughness of Parklands quality management
infrastructure and systems throughout Parkland. The QRO shall assess Parklands efforts
to achieve compliance with its Clinical Quality Policies and Procedures described in
Section III.B.2.b-c, the Medicare Conditions of Participation, and other standards
designed to ensure that the delivery of patient care items or services at Parkland meet
professionally recognized standards of health care and are reasonable and appropriate to
the needs of Federal health care program beneficiaries. The Clinical Quality Systems
Review will be undertaken at all relevant levels of the organization. The QRO shall
assess, among other things, the effectiveness, reliability, and thoroughness of the
following:
1.
Parklands quality management infrastructure, including but not
limited to an assessment of:
a.
b.
c.
d.
57
2.
assessment of:
3.
accordance with:
e.
f.
g.
b.
c.
d.
e.
f.
g.
b.
c.
d.
e.
4.
Parklands identification and response to Reportable Quality Events,
as required by Section B of this Appendix D.
B.
1.
Definition of Reportable Quality Event. For purposes of this CIA, a
Reportable Quality Event means anything that involves:
a.
b.
c.
Suicides;
d.
e.
Never events;
f.
g.
2.
If Parkland determines (after a reasonable opportunity to conduct an
appropriate review or investigation of the allegations) through any means that there is a
Reportable Quality Event, Parkland shall notify the QRO, in writing, within 60 days after
making the determination that the Reportable Quality Event exists.
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3.
For Reportable Quality Events, the report to the QRO shall include:
a.
b.
c.
d.
4.
Parkland shall provide all reports to the QRO of Reportable Quality
Events to its Compliance Committee, Quality, Safety, and Performance Improvement
Department, Audit and Compliance Committee, and Quality of Care and Patient Safety
Committee.
C.
1.
immediate access to Parkland, at any time and without prior notice,
to assess the effectiveness of the internal quality assurance mechanisms, and to ensure
that the data being generated is accurate;
2.
b.
c.
d.
e.
f.
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g.
h.
i.
patient records;
j.
k.
3.
immediate access to patients and Covered Persons for interviews
outside the presence of Parkland supervisory staff or counsel, provided such interviews
are conducted in accordance with all applicable laws and the rights of such individuals.
The QRO shall give full consideration to an individuals clinical condition before
interviewing a patient.
D.
The QRO shall prepare a report based upon each Clinical Quality Systems Review
performed (Clinical Quality Systems Review Report).
1. the Clinical Quality Systems Report shall set forth, at a minimum:
a.
b.
c.
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E.
d.
e.
1.
abide by all State and Federal laws and regulations concerning the
privacy, dignity, and employee rights of all Covered Persons and patients;
2.
abide by the legal requirements of Parkland to maintain the
confidentiality of each patients personal and clinical records. Nothing in this subsection,
however, shall limit or affect the QROs obligation to provide information, including
information from patient clinical records, to OIG, and, when legally or professionally
required, to other agencies;
3.
where independently required to do so by applicable law or
professional licensing standards, report any finding to an appropriate regulatory or law
enforcement authority, and simultaneously submit copies of such reports to OIG and to
Parkland;
4.
not be bound by any other private or governmental agencys findings
or conclusions, including but not limited to the Joint Commission, CMS, or the state
survey agency. Likewise, such private and governmental agencies shall not be bound by
the QROs findings or conclusions. The QROs reports shall not be the sole basis for
determining deficiencies by the state survey agencies. The parties agree that CMS and its
contractors shall not introduce any material generated by the QRO, or any opinions,
testimony, or conclusions from the QRO as evidence into any proceeding involving a
Medicare or Medicaid survey, certification, or other enforcement action against Parkland,
and Parkland shall similarly be restricted from using material generated by the QRO, or
any opinions, testimony, or conclusions from the QRO as evidence in any of these
proceedings. Nothing in the previous sentence, however, shall preclude OIG or Parkland
from using any material generated by the QRO, or any opinions, testimony, or
conclusions from the QRO in any action under the CIA or pursuant to any other OIG
authorities or in any other situations not explicitly excluded in this subsection;
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5.
abide by the provisions of the Health Insurance Portability and
Accountability Act (HIPAA) of 1996 to the extent required by law including, without
limitation, entering into a business associate agreement with Parkland; and
6.
if the QRO has concerns about systemic problems that could affect
Parklands ability to render quality care to its patients, then the QRO shall:
a.
b.
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