Mastering the Compliance Manual

August 5, 2020 to August 6, 2020

This is a private virtual training developed for and hosted by the Montana Primary Care Association (MTPCA) as a benefit for their members.

If you are not a member but interested in training on the Compliance Manual, please review our HRSA Program Requirements page or Contact Us.


In the past few years, HRSA has transitioned its compliance efforts for Federally Qualified Health Centers (FQHCs) from multiple policy guidance documents to the Health Center Program Compliance Manual, a consolidated resource to assist FQHCs in understanding, demonstrating and operationalizing compliance. The Manual, which supersedes most (but not all) prior guidance, incorporates a new approach to “everyday compliance” by addressing each requirement’s statutory and regulatory basis, the key elements of compliance that collectively form the framework of every health center’s project, and areas for which health centers maintain discretion.

To assist in evaluating compliance, HRSA issued a Site Visit Protocol, which aligns with the Manual and reflects a more objective assessment tool than prior review guides. HRSA’s most recent Protocol clarifies the documentation requirements and assessment methodologies used by HRSA to verify compliance during both on-site reviews (Operational Site Visits - OSVs) and “desk audits” of applications for grant project period and FQHC look-alike designation renewals.

There is an expectation of 100% ongoing compliance with the Health Center Program Requirements. Is your health center prepared to meet this challenge? Have you reviewed the most recent HRSA guidance and assessment processes with an eye towards shoring up your own operations and establishing your HRSA compliance work-plan? For example,

  • Is your Form 5A up to date, based on HRSA’s service definitions and correct modes of delivery?
  • Do you have written contracts and referral agreements in place for services listed in columns II and III of Form 5A, and do they include all required provisions, including sliding fee discounts and provisions under 45 CFR Part 75?
  • Are members of your clinical staff (including staff members like dental assistants, medical assistants and community health workers) appropriately credentialed and privileged?
  • Does your quality improvement system meet all current standards?
  • Do you have systems in place to assess all patients for income and family size? Have you implemented mechanisms to inform patients about the sliding fee discount program and to conduct an effectiveness evaluation of the program?
  • Do you have billing and collection policies that address the waiver / reduction of payments and other processes that help strike the balance between maximizing reimbursement and maintaining optimum access?
  • Is your financial management system sufficient for federal accountability purposes?
  • Is your Board of Directors exercising all required authorities, and do you have documentation to verify compliance?

Join FTLF for this hands-on training covering:

  • The Compliance Manual and Site Visit Protocol, including the elements of each programmatic requirement, the documentation required to verify compliance, assessment methodologies designed for various elements, and areas where health centers retain explicit discretion and flexibility;
  • How the legal requirements intersect with the reviewers’ interpretations;
  • Key high-risk areas from recent compliance reviews;
  • Compliance tips from our presenters’ years of experience working first-hand with hundreds of health centers prior to, during and after their OSVs; and
  • Guidance on responding to preliminary findings during HRSA’s Compliance Resolution Opportunity to avoid grant conditions.

Target Audience

  • Health Center Executive Staff
  • Clinical Leadership
  • Quality and Credentialing/Privileging Staff
  • Financial Leadership and Staff
  • Compliance Officers
  • Administrative / Operations Leadership and Staff
  • Board members
  • Other Staff assisting with HRSA compliance and/or OSV preparation

Learning Objectives

After this training, you will be able to:

  • Identify the elements of the HRSA programmatic requirements addressed in the Manual and the Protocol.
  • Describe the specific documentation and assessment process necessary to demonstrate compliance and areas where health centers retain discretion.
  • Discuss the newest compliance tips for all phases of the HRSA compliance review (before, during and after) and use such tips to establish your health center’s HRSA compliance workplan.
Course summary
Available credit: 
  • 12.75 Certificate of Attendance
Course opens: 
07/31/2020
Course expires: 
01/07/2021
Event starts: 
08/05/2020 - 9:00am
Event ends: 
08/06/2020 - 5:30pm
Wednesday, August 5, 2020 - Thursday, August 6, 2020
*All specific agenda times are subject to change*

NOTE: The following two sessions will NOT be addressed in the virtual workshop:

  • Introduction to the Health Center Program Compliance Manual and HRSA Review Process
  • Working within the “Box”: Key Elements and Requirements of Scope of Project

Both topics are available in pre-recorded webinars through this course page. To view, click the gray "Take Course" button on either the "Overview" or "Register" tab once you have registered for the course.

Day 1

Wednesday, August 5, 2020
9:00 am - 5:15 pm MT
9:00 am - 9:30 am MTIntroduction to the Training and Health Center Compliance
9:30 am - 10:45 am MT
The "Community" in Community Health Center: The Governing Board of Directors (Chapters 19 & 20)
10:45 am - 11:00 am MTBreak
11:00 am - 12:00 pm MTQuality is Key (Chapter 10)
12:00 pm - 12:15 pm MTBreak
12:15 pm - 1:15 pm MT
The Right Care Delivery Team to Achieve Your Health Center Program Goals (Chapter 5)
1:15 pm - 2:00 pm MTLunch
2:00 pm - 3:15 pm MTThe Heart of Your Health Center Project: Need, Services & Continuity of Care - Part 1 (Chapters 3, 4, 6, 7, 8, 14)
3:15 pm - 3:30 pm MTBreak
3:30 pm - 4:30 pm MTThe Heart of Your Health Center Project: Need, Services & Continuity of Care - Part 2
4:30 pm - 4:45 pm MTBreak
4:45 pm - 5:15 pm MTPersonnel Dynamics - Ensuring Appropriate Key Management Staff (Chapter 11)
 

Day 2

Thursday, August 6, 2020
9:00 am - 5:30 pm MT
9:00 am - 10:00 am MTInternal Controls and Ensuring Fiscal Viability - Part 1 (Chapters 17, 15, 12, 13)
10:00 am - 10:15 am MTBreak
10:15 am - 11:15 am MTInternal Controls and Ensuring Fiscal Viability - Part 2
11:15 am - 11:30 am MTBreak
11:30 am - 12:45 pm MTInternal Controls and Ensuring Fiscal Viability - Part 3
12:45 pm - 1:30 pm MTLunch
1:30 pm - 2:30 pm MTEnsuring the Core Mission: Making Care Affordable While Maximizing Reimbursement - Part 1 (Chapters 16 & 9)
2:30 pm - 2:45 pm MTBreak
2:45 pm - 3:45 pm MTEnsuring the Core Mission: Making Care Affordable While Maximizing Reimbursement - Part 2
3:45 pm - 4:00 pm MTBreak
4:00 pm - 5:15 pm MT

Ensuring the Core Mission: Making Care Affordable While Maximizing Reimbursement - Part 3

It's All About the Data (Chapter 18)

5:15 pm - 5:30 pm MTQuestions & Wrap-Up
This live, interactive training will be hosted by the Montana Primary Care Association.  

MOLLY EVANS  

A Partner in the firm’s health law practice group, Molly advises health centers on the management of clinical, employment and workforce related risks, with a particular focus on professional liability, Federal Tort Claims Act, and HIPAA matters. From her experience as both a private attorney and in-house counsel, Molly knows the importance of managing liability and risk issues in mission-driven organizations. [Full Bio]

TED WATERS

Serving as Managing Partner of the firm since 2003, and a member of the Health Law and Federal Grants practices since 1992, Ted is a national authority in the area of federal grants, particularly in the health and community service spheres. He advises clients on all aspects of program requirements, including issues such as cost-based reimbursement, governance and the never-ending list of grant administration matters. Ted’s expertise in financial, cost reporting, reimbursement, and administrative issues is widely recognized and he routinely handles government audits, internal investigations, and litigation. [Full Bio]

MARCIE ZAKHEIM

A Partner at the firm, Marcie specializes in health care law, particularly in the areas of federal grants, grant-related requirements and grants management related to the federal health center program. Health centers turn to Marcie as a resource for knowing not only the letter of the law, but also the likely interpretation of requirements by federal policymakers, including the Health Resources and Services Administration (HRSA). [Full Bio]

This course does not offer continuing education credits.

Certificate of Attendance is available for the attendee immediately following the completion of the training. To view and download this certificate, navigate to the Registration tab and click "Take Course" followed by "Certificate".

Available Credit

  • 12.75 Certificate of Attendance
Please login or register to take this course.

This is a private virtual training developed for and hosted by the Montana Primary Care Association (MTPCA) as a benefit for their members. If you are a member, please contact MTPCA directly for the access code.

If you are not a member but interested in training on the Compliance Manual, please review our HRSA Program Requirements page or Contact Us.


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