Looking for the February 2023 OSV training?  Please click here. 

At the start of the COVID-19 pandemic, HRSA transitioned and re-focused its compliance efforts for Federally Qualified Health Centers (FQHCs) from an on-site compliance assessment to a virtual process that mirrors the in-person reviews.  Using lessons learned from the virtual Operational Site Visit (OSV), HRSA is currently “pilot testing” a new approach that strives for both compliance and excellence by combining aspects of the virtual process with desk audits and pre-OSV support through technical assistance sessions on the Health Center Program Requirements.  Regardless of the specific process used for your OSV, compliance with health center program requirements is still a vital component of a health center’s daily operations. . .and non-compliance findings may result in legal consequences impacting such operations and your ability to serve your patient populations and your community at large.

Whether virtual or on-site, the OSV process revolves around 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 an “ongoing compliance” approach by addressing each requirement’s statutory and regulatory bases, 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 conducting a “hands-on” compliance assessment, HRSA reviewers utilize the Site Visit Protocol, which aligns with the Manual and reflects a more objective assessment tool than prior review guides. HRSA’s most recent Protocol, which is effective for both the virtual OSVs and the new pilot program, clarifies the documentation requirements and assessment methodologies used by HRSA to verify compliance.

As in the past, 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 such as 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? Does your sliding fee discount schedule apply to all in-scope services and have you implemented mechanisms to ensure input from your Board members when establishing the sliding fee discount schedule and nominal fee and conducting 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 independently exercising all required authorities, without limitation, and do you have documentation to verify compliance?

Join FTLF for this training exploring:

• The virtual OSV process and how it differs from (and is the same as) the onsite process;
• How to use the Compliance Manual, the most recent Site Visit Protocol, and other HRSA-issued compliance guidance to prepare for your OSV, including discussion of the elements of the programmatic requirements and the documentation and assessment methodologies required to verify compliance with each, as well as 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; and
• Compliance tips from our presenters’ years of experience working first-hand with hundreds of health centers prior to, during, and after their OSVs.