Virginia Care Partners, Accountable Care Organization, LLC

Compliance Plan

Virginia Care Partners, Accountable Care Organization, LLC (VCP ACO) has established the following Compliance Plan in accordance with 42 CFR § 425.300 (the Compliance Program). VCP 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 VCP ACO.

The Compliance Program includes the following:

A designated compliance official or individual who is not legal counsel to the ACO and reports directly to the ACO’s governing body.

VCP 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 ACO 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 VCP ACO, and reports directly to the Board of Managers.

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 to ensure compliance with policies and/or to identify issues, implementing appropriate corrective action 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 on the status of the Compliance Program including Compliance Program updates, changes to any applicable laws, rules, and regulations, reported incidents, investigations, and monitoring activities. The report will be documented in the minutes of such Board meeting. The Compliance Officer may make additional reports 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 ACO's operations and performance (e.g., internal risk assessment 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

VCP ACO Compliance Plan January 2020 Page 2

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 VCP ACO will also conduct monitoring. The effectiveness of the Compliance Program is, in part, assessed in these ongoing efforts.

Through its agreement with HCA, VCP ACO uses an Internal Compliance Reporting System to identify risk areas of significant liability including issues involving fraud waste and abuse, 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. There is no retribution or discipline for anyone who reports a concern in good faith.

For all identified and reported compliance concerns, prompt investigation will occur when potential non-compliance is communicated to the Compliance Officer. The Compliance Officer may raise concerns directly with the Board if and as necessary without fear of retaliation. Once the investigation is complete, appropriate corrective action will be undertaken to prevent future occurrences. These changes 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, VCP ACO will promptly report to the appropriate authority.

A method for employees or contractors of the ACO, ACO participants, ACO providers/suppliers, and other individuals or entities performing functions or services related to ACO activities to anonymously report suspected problems related to the ACO to the Compliance Officer.

Through its agreement with HCA, VCP ACO uses an internal reporting mechanism, in which callers may choose to remain anonymous, called the Ethics Line for employees and contractors to 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 at http://hcahealthcareerthicsline.ethix360.com. 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, https://hcahealthcare.com/ethics-compliance/ethics-line.dot, and in the HCA Code of Conduct which is also posted on HCA’s internet site. It will also be available on the VCP internet site. Contact information for and use of the Ethics Line is further addressed in compliance training for VCP ACO.

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 local VCP ACO log maintained by the Compliance Officer along with any other issues of compliance concern brought to the Compliance Officer's attention.

The Compliance Officer may raise concerns brought to light through the Ethics Line or otherwise communicated to the Compliance Officer directly with the Board if and as necessary without fear of retaliation.

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.

Compliance training for the ACO, the ACO participants, and the ACO providers/suppliers

The Compliance Officer helps to ensure through training and communications that employees, contractors, ACO participants, and ACO providers and suppliers are aware of the Compliance Program, including HCA’s Code of Conduct. The Code of Conduct and other HCA policies are available to employees on the HCA intranet and to contractors, ACO participants, ACO providers and suppliers through the HCA internet site. The Compliance Officer will periodically update Compliance Program training materials to respond to changes in the law and industry that impact VCP ACO and will communicate those revisions to those providing services to VCP ACO.

VCP ACO 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, as well as content on top identified risk areas.

Specialized compliance training is developed in particular risk areas by HCA's Responsible Executives and the Ethics and Compliance Department. The Compliance Officer works with Responsible Executives and the VCP ACO to ensure that employees, contractors, ACO participants, and ACO providers and suppliers are aware of the laws, rules, regulations and ethical standards that apply to Accountable Care Organizations and other relevant health care program requirements. Specialized training is delivered to these groups as needed.

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 be 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.

VCP 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.

VCP ACO follows HCA’s Company process for analyzing issues to determine if a probable violation of law has occurred. This includes engaging Responsible Executives, members of the Corporate Ethics 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 will do so on behalf of VCP ACO.

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