I love sports, particularly baseball, so when I submitted my presentation to the Health Care Compliance Association (HCCA) for consideration as a session at the 2022 Clinical Practice Compliance Conference,[1] I knew that it had to be based on a baseball metaphor, hence the title as a reference to Field of Dreams. The analogy works perfectly when considering what it takes to build a compliance program of any kind; it resonated with me when I reflected upon my journey to build and implement a physician compliance program at Orlando Health, a comprehensive health system headquartered in Orlando, Florida.
I have divided this article into five sections: The field, the players, the playbook, the bench, and the on-deck circle. The field briefly discusses the Orlando Health landscape; the players describe the key operational leaders and departments who contribute to the success of the physician compliance program; the playbook summarizes key components of the program; the bench offers some thoughts on the initiatives that were ultimately (and appropriately) shelved, and the on-deck circle outlines our plans for 2023.
The field
The timing for hiring the senior director of physician compliance role came at a perfect time as the practices employed by Orlando Health were moving under the umbrella of Orlando Health Medical Group (OHMG). Prior to use of the OHMG name, practices were branded differently, and affiliation with Orlando Health was not always apparent to the public. Additionally, different reporting structures, policies, and disparate medical records systems created inconsistency for providers and patients.
Since I became the senior director of physician compliance in July 2017, Orlando Health has acquired two hospitals with employed physician groups, three large multispecialty practices, a multitude of smaller practices, and implemented two new services lines where practice acquisitions and additional hiring of providers occurred.
Today, OHMG has over 275 practice locations and 10 different service lines with over 1,400 physicians and advanced practice providers in nine counties.
The players
Senior director of physician compliance
My hiring process included meetings with the chief compliance and ethics officer and other directors in the compliance and ethics department responsible for internal audit, hospital and corporate compliance, and privacy and information security. I also submitted a 90-day action plan that outlined the steps I wanted to take should I be selected for the role. I was brand new to compliance, as my previous experience had been as an administrative fellow, a project manager, process improvement specialist, manager of operations for a clinically integrated network in South Florida, and then as the manager of physician enterprise administration for Orlando Health’s clinically integrated network. Most of my roles had included work with physicians, though, and the chief compliance and ethics officer and I made a deal: if he was willing to teach me compliance, then I was willing to learn.
I leaned heavily on my fellow directors and their teams, especially during my first few months on the job. I still do. We are now a department of 17 and a pretty close-knit group. I had a goal to obtain my Certification in Healthcare Compliance, which I did 15 months after starting my role. I also attended an evaluation and management (E/M) coding workshop offered by the local chapter of the American Academy of Professional Coders and the HCCA Clinical Practice Compliance Conference. These steps were crucial cornerstones for building my foundation of compliance knowledge.
I was a team of one—with support from the compliance and ethics department—until July 2021, when we hired our manager of physician compliance. As much work as there was to do, I am glad we strategically waited to make that first hire, as I had to build a program to give a person something to step into and develop a plan for growth so we knew where we needed to go when she started.
President of OHMG
The president of OHMG started in September 2017, and we met fairly soon afterward. He set up travel days to visit the various practices and physicians that would make up OHMG. These visits included the service line’s assistant vice president (AVP), sometimes a physician relations manager who already had relationships with the practices, and me. This helped set the tone early that operations and compliance would have a close relationship.
Vice president of OHMG
The first vice president (VP) of OHMG had been promoted to that role from an AVP position. She and I established a quarterly meeting cadence where we discussed compliance hotline calls, new initiatives, or any outstanding issues that needed follow-up. She later moved into a different role, and I met with the new VP soon after he started. We continue to collaborate on various issues.
AVPs of OHMG
Each OHMG service line has its own AVP. As OHMG was formalizing its structure, more AVPs were added to the team, and I became a part of their onboarding process. Today, I work with them regularly to address compliance hotline calls, providers who may have accessed medical records inappropriately, and conflicts of interest disclosure forms that need to be completed. I partner with them to recruit ambassadors for our OHMG Compliance Ambassador Program, which I’ll discuss in more detail. I also work with AVPs and other OHMG leadership team members during electronic medical records committee meetings, the OHMG clinical and operational optimization committee meetings, and the OHMG policy and procedure committee.
Medical staff services
I established relationships with the director of medical staff services, the operations manager, and the medical staff services liaisons early on. We work with the liaisons on various education initiatives and request their assistance obtaining conflict of interest forms for our nonemployed physician leaders. At Orlando Health, chiefs and vice chiefs rotate every two years, so I try to get to know them each time new leadership takes the helm.
Other key relationships
It was also critical for me to establish relationships with revenue management, the central business office (which processes all of the OHMG billing), legal affairs, risk management, value-based care (this was easier as this was the department I transferred from), and physician contracting. I speak to leaders from these departments daily, and we consistently collaborate with each other.
The playbook
Value-based care compliance
One of my first tasks was to review the recommendations that had recently been drafted by an outside consultant on the compliance program for Orlando Health’s accountable care organization (ACO), Orlando Health Collaborative Care (OHCC). The recommendations included developing and implementing a formal ACO compliance program including policies and establishing a compliance committee. This was a good first project for me to work on, since it bridged the gap between my former and new departments.
Today, the OHCC compliance committee consists of the chief compliance and ethics officer, the VP of value-based care and population health, the director of risk adjustment and quality programs, and me. The compliance committee meets at least annually to review policies, conflicts of interest disclosures made by board and committee members, compliance hotline call reports, and to discuss ACO performance and participation updates.
I also attend the OHCC board meetings, as well as the board meetings for Orlando Health Network, OHI’s clinically integrated physician network. Both networks consult with the physician compliance team and legal affairs in developing patient-facing initiatives to ensure anything they pursue remains compliant with the updates made to the Stark Law regarding value-based care.
Provider education
Physician compliance topics are presented twice a month at new provider orientation for new medical staff members. We cover the fraud, waste, and abuse laws, Orlando Health’s Gifts and Business Courtesies policy, email security, phishing prevention, and how to report compliance concerns. We partner with our chief privacy officer to provide resident orientation on an annual basis, which is a more comprehensive education session covering the topics previously discussed, as well as nondiscrimination education and other Orlando Health compliance and privacy policies. Orientation is also provided for new providers and team members of acquired groups and occurs on an as-needed basis.
The physician compliance team works with the medical staff services liaisons to schedule a presentation at each medical staff department meeting at each hospital annually to provide a fraud, waste, and abuse update. We scour the U.S. Department of Health & Human Services Office of Inspector General (OIG) enforcement actions webpage to find at least two specialty-specific articles to present at each meeting.
We remind the providers that we are not presenting these cases because we think these activities are happening at Orlando Health but to walk them through what a government investigation could look like, as well as the consequences for providers convicted of fraud. When the OIG released its Special Fraud Alert: Speaker Programs in November 2020,[2] we spent 2021 sharing the fraud alert with our providers. We resumed the fraud, waste, and abuse presentations in 2022 and presented at 35 different meetings.
We also have a presentation for OHMG team members and physicians that we like to do in the practices, so we can also complete the OHMG Physician Practice Compliance Assessment, which evaluates if the correct required compliance signage is in place and that best privacy and information security practices have been implemented.
OHMG Compliance Ambassador Program
We established the OHMG Compliance Ambassador Program in 2019 to empower team members in the practices to serve as “local” compliance resources. With the support of the Orlando Health CEO, we have advertised participation in the program as a leadership development opportunity for team members. Many ambassadors are promoted before they complete the program, and the current manager of physician compliance is a former ambassador.
The AVP of each service line must nominate ambassadors. Our goal is to have three ambassadors from each service line, and some service lines now have a wait-list of team members interested in participating. Each year, we review those on the wait-list first with the AVP to determine if they would be a good fit before soliciting additional ambassadors from that service line. Ideal ambassadors are front office assistants, team assistants, medical assistants, scheduling coordinators, and supervisors. Past ambassadors have included practice managers and directors, nurses, and a physician assistant, but sometimes these roles make it difficult for the ambassador to fully participate in the program.
The program structure requires attendance at four one-hour webinars a year. Webinars are scheduled but makeup sessions are always provided since a day in a practice can be unpredictable. Ambassadors are assigned a zone of practices based on geography. They have the opportunity to interact with other service lines as they complete their monitoring activities each quarter. Past monitoring activities have included mini-audits, interviews with team members, and giving presentations on what they have learned in the program. The final quarterly component of the program is to read and react to an article posted in our group on our learning management platform. The program culminates in a luncheon for the ambassadors. OHMG and compliance and ethics leadership are invited to attend to recognize and celebrate the excellent work the ambassadors have done over the past year.
Provider documentation, coding and billing audit program
Orlando Health has been auditing provider documentation, coding and billing for years; however, in 2022 the physician compliance and internal audit teams took over responsibility for the contractual relationship with the third-party auditor, the development and maintenance of the audit and reaudit schedule, sample selection of the claims to be audited, and the tracking and reporting of results and provider education sessions that are conducted by the physician coding education team.
The audit consists of a review of 15 E/M claims per provider and 10 procedures for any proceduralist. Providers who do not meet the minimum number of encounters to be audited are reviewed again later in the audit cycle, which is currently 18 months long. Incident-to and split-shared billing claims are also reviewed to ensure compliance with current documentation guidelines.
Providers who score a 90% or higher on the E/M portion of the audit will be reaudited 18 months after their initial audit; providers who score between 80% and 89% will be reaudited in nine months, and providers who score less than an 80% will be reaudited in four months and are required to meet with a physician coding education specialist. A member of the physician compliance team attends those education sessions whenever possible. Audit results are shared with the finance and audit committee of the Orlando Health board of directors, the executive compliance and ethics committee, and the enterprise billing compliance steering committee.
The bench
OHMG policy committee
When I first became the senior director of physician compliance, I was trying to understand what policies were in place at OHMG; I quickly realized that not many policies were applied consistently across the medical group. Many of the policies were outdated or were considered to be standard operating procedures kept within the practices. After taking inventory of current policies and identifying which could be updated for OHMG, a committee was formed to review and update the policies. I had been nominated to serve as the chair but realized that this project was bigger than just compliance. We implemented three operational policies before pausing the committee’s work to focus on our upcoming comprehensive electronic health record (EHR) implementation. We knew that just about every policy would need to be updated to reflect the new workflows required by the EHR.
Today the committee is led by one of the senior directors from the Orlando Health Cancer Institute, and there is representation from a variety of areas, including physician compliance, referral management, nursing operations, and risk management. There is also a multistep approval process in place to ensure everyone can offer their input. The internal audit team maintains the OHMG policy repository on our corporate intranet, and once policies are approved, they are uploaded and available for all OHMG team members.
Ambulatory surgical center compliance program
Orlando Health began opening joint venture ambulatory surgical centers in 2019. I wrote the first draft of a compliance plan we intended to implement at each center, and this was ultimately transitioned to the corporate compliance team for ongoing monitoring. Since each surgery center is its own legal entity, plans must be approved by each center’s board of directors. Each center submits its own reporting to the corporate compliance team. All compliance and ethics directors continue to meet with the ambulatory surgical center leadership team every month.
Research compliance program
I conducted initial meetings with the leaders from the Orlando Health corporate office of research operations; now, a formal research compliance program is currently being implemented under the direction of the corporate compliance team.
Ultimately, each of these initiatives ended up with the best team in our organization, which has allowed physician compliance to spend more time on provider-specific issues.
The on-deck circle
Refine the OHMG documentation, coding and billing audit program
The current audit cycle ends in June 2023. In March, we began revising our program document to plan for the next 18-month cycle and have several initiatives under consideration. We would like to increase the minimum passing score. We are considering separating the procedure audit process from the E/M audit process. While providers select their own E/M levels, professional coders code the procedures. Therefore, if a provider fails a procedure audit, the coder is the one who receives the education. Since providers can have several different coders working on their cases, we want to ensure that we are auditing and reauditing procedures by the coder rather than the provider. We would also like to continue to diversify our audit portfolio to include more audits on medical necessity, episodic care, and use of specific modifiers.
Expand OHMG compliance ambassador program
As OHMG continues to grow, so will the Compliance Ambassador Program. We added a radiology service line to OHMG in October 2022, and they have committed three ambassadors to serve in the program’s next class. We also plan to increase the in-person engagement between ambassadors and their assigned practices.
Expand physician compliance role in physician contract evaluation
We plan to continue to work closely with the physician compensation and OHMG leadership teams as they evaluate physician compensation methodologies. Changes in reimbursement and practice patterns have necessitated further conversations at Orlando Health, and physician compliance will have a seat at the table.
Summary
Overall, the past five years have been incredibly rewarding. About a year into my role, one of the AVPs—who is now the president of one of our hospitals—asked me if I was comfortable in my role. My answer was, “Definitely not!” I think most of my colleagues would agree that compliance is not the type of profession that lends itself to comfortability. While I feel more experienced in my role, I am still always trying to answer the question, “What’s next?” I think the very fact that I cannot answer this question is why I enjoy working in compliance. I wanted to be challenged when I took this role, and every day offers the opportunity to respond to that challenge.
Takeaways
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Support from leadership is crucial to building a successful physician compliance program.
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Building relationships with other departments early on is critical.
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Include employed and nonemployed physicians and advanced practice providers in your education strategy.
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Build an audit program that can be flexible to meet the needs of the providers.
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Be willing to let go of initiatives other departments may be better suited to lead.