First Healthcare Compliance CONNECT January 2022

CONNECT
January 2022
A Monthly Publication for the Healthcare Compliance Community
FAQ Corner: What Federal
notices/posters are required
in the workplace?
Infographic:
Get Rid of PHI Securely
What you need to
know about the
No Surprises Act
Q&A: Expanded Roles and
Duties for Medical Assistants
during the COVID-19 Era
1st Talk Compliance: What
You Need to Know about The
No Surprises Act

Got a Minute? Please Rate Us!
The health of our company depends on the members
of our community spreading the word about us.
Share Your Success Story
An endorsement by you is the greatest compliment
we could receive! Please take a moment of your time
to rate us online so that others can benefit from your
experience. It’s a simple way to help us grow and
improve.
We appreciate your support and look forward to
hearing from you!
In This Issue:
Compliance Super Ninja
FAQ Corner: What Federal notices/posters are
required in the workplace?
Infographic: Get Rid of PHI Securely
What you need to know about the No
Surprises Act
Q&A: Expanded Roles and Duties for Medical
Assistants during the COVID-19 Era
2
First Healthcare Compliance, LLC © 2022

Compliance Super Ninja
Tanna Dotson, Clinic Manager
Associated Vitreoretinal & Uveitis Consultants
How would you describe your experience with First Healthcare Compliance?
Great, when I started at this practice 15 years ago, we only had 12 employees and now we’ve grown to almost
50. Having First Healthcare Compliance has greatly improved our compliance and helped me transition to a
large practice.
What do you enjoy most about working with Associated Vitreoretinal & Uveitis
Consultants?
We are a very busy retina practice in Indiana. We have four amazing doctors. I enjoy being a part of this team
and the great work that we do each year.
Would you rather have a two-bedroom apartment in a big city or a mansion in the
countryside? Why?
I would prefer to be in the countryside. My husband and I currently live on a few acres and it is a nice change
from the busy roads and shops near work.
1st Talk Compliance: The No Surprises Act –
What You Need to Know
COVID-19 Healthcare Compliance Toolkit
Contact Toll Free: 888-54-FIRST 3

FAQ Corner
What Federal notices/posters are required in the workplace?
Employers are required to advise employees of their federal rights in the form of displaying federally required posters
in the workplace. Compliance with these federal requirements are necessary to avoid strict fines and penalties. Here
is a listing of posters that are required by federal law, including direct links:
Fair Labor Standards Act (FLSA) Poster
FSLA establishes minimum wages, overtime pay, record keeping and child labor standards for private sector and
government workers.
• Every employer of employees subject to the FLSA’s minimum wage provisions is required to display the poster.
• The poster must be prominently displayed in all establishments, where it can be readily seen by employees.
The Equal Employment Opportunity Poster
The Equal Employer Opportunity Commission (EEOC) enforces federal non-discrimination laws which prohibit job
discrimination based on race, color, sex, national origin, religion, age, equal pay, disability or genetic information.
• Employers with 15 or more employees are required to display the poster.
• The poster must be prominently displayed in all establishments, where it can be readily seen by employees and
job applicants.
The Most Comprehensive
Healthcare Compliance Course
The Fundamentals is a user-friendly, four-module
online course designed to help healthcare professionals
understand the essential principles and practices of
compliance.
BUY COURSE NOW
4
First Healthcare Compliance, LLC © 2022

The Family And Medical Leave Act (FMLA)
Poster
The FMLA provides employees with 12 months of
service and with at least 1,250 hours worked during the
last 12 months with up to 12 weeks of job-protected,
unpaid leave for: 1) the birth and care of a newborn
child; 2) the placement for adoption of child; 3) one’s
own serious health condition; or 4) the serious health
condition of an immediate family member.
• Every employer with 50 or more employees
within a 75-mile radius is required to display
the poster, even if there are no FMLA eligible
employees.
• The poster must be prominently displayed in all
establishments, where it can be readily seen by
employees and job applicants.
Occupational Safety And Health Act
(OSHA) Poster
OSHA requires employers to provide employees with
a workplace that is free from recognized hazards that
are causing or likely to cause death or serious physical
harm.
• All private sector employers are required to
display the poster.
• The poster must be prominently displayed in all
establishments, where it can be readily seen by
employees.
• Posters must be at least 8.5” x 14” inches with
10 point type.
• Although not a requirement, OSHA recommends
employers to display the Spanish version
of the poster if they have Spanish-speaking
employees.
The Employee Polygraph Protection Act
(EPPA) Poster
The EPPA prohibits employers from using lie detector
tests for pre-employment screening of job applicants or
for testing current employees.
• All private sector employers are required to
display the poster.
• The poster must be prominently displayed in all
establishments, where it can be readily seen by
employees and job applicants.
Uniformed Services Employment And
Reemployment Rights Act (USERRA)
The USERRA requires that returning service members
are entitled to receive all rights and benefits of
employment that they would have obtained if they had
been continuously employed.
• All employers are required to display the poster.
• The poster must be prominently displayed in
all establishments or distributed in full text to
employees in writing or via electronic mail.
In addition to federal requirements, employers should
check with their respective state agencies regarding
required posters or notices.
Explore the FAQs tab in your compliance solution
to find answers to your compliance questions!
CLIENT
ALERT
Contact Toll Free: 888-54-FIRST 5

6
First Healthcare Compliance, LLC © 2022

Risk Management Considerations for
the Healthcare Compliance Officer:
Training, Incident Management, Governing Boards,
and Measures Unique to COVID-19
It’s no secret that healthcare is one of America’s most heavily regulated
industries with substantial fines and penalties for non-compliance. Complex
regulations and mandates make compliance management a necessity.
Healthcare organizations particularly rely on the skills and attributes of their
compliance officer to navigate the expansive regulatory framework.
DOWNLOAD NOW
Contact Toll Free: 888-54-FIRST 7

What You Need To Know
About The No Surprises Act
Guest Author
Rachel V. Rose, JD, MBA
Enacted in late 2020 as part of the
Consolidated Appropriations Act of 2021
with an effective date of Jan. 1, 2022, the No
Surprises Act (NSA) underscores its primary
purpose is to protect patients from surprise
medical bills when receiving certain services
from – emergency services, non-emergency
services from nonparticipating providers at
participating facilities, and air ambulance
service from nonparticipating providers. (86
Fed. Reg. 36872 (Jul. 13, 2021)).
Essentially, the NSA does three things: (1) limits
a patient’s cost-sharing to in-network levels; (2)
prohibits balance billing; and (3) establishes an
independent dispute resolution process (IDR). The
NSA’s IDR enables payors and providers to resolve
disputes over provider payments. 86 Fed. Reg. at
36875–76. As the Centers for Medicare and Medicaid
Services (CMS) state, “[m]ost group health plans
and health insurance issuers that offer group or
individual health insurance coverage have a network
of providers and health care facilities (in-network
providers) that agree to accept a specific payment
amount for their services.”
Three federal agencies are tasked with implementing
the NSA – Department of Treasury, Department of
Labor, and the Department of Health and Human
Services (collectively “Agencies”). These Agencies
have published two sets of Interim Final Rules (IFRs)
and a Notice of Proposed Rulemaking in preparation
for the NSA’s effective date.
The Oct. 7, 2021, IFR addresses the IDR process.
There is a comment period that closed on Dec. 6,
2021. Here are the steps that are outlined in the
Federal Register:
• Initiating party sends a required form with
sufficient information to identify the disputed
services within 30 business days from the date
the provider or facility receives initial payment
or denial of payment. This 30-business-day
open negotiation period enables the parties to
negotiate an agreed rate by the last day and if
an agreement is not reached, then either party
may initiate IDR.
• To initiate IDR, within four business days
following the end of an open negotiation period,
a party submits a notice through the federal IDR
portal, which is a public website maintained by
CMS.
8
First Healthcare Compliance, LLC © 2022

• The initiating party must do the following:
identify its preferred, certified IDR entity and
include material information about the dispute,
including the “qualifying payment amount”
(QPA). The QPA is basically the plan or issuer’s
median in-network rate.
• Once the IDR entity is selected, within 10
business days, the parties each submit
a respective offer for a payment amount
expressed both as a dollar amount and as a
percentage of the QPA. A description of the
party is also required – for example a provider’s
practice size and specialty. Other information
may also be submitted; however, there are also
exclusions such as the Medicare Fee Schedule.
• Within 30 business days after the IDR entity’s
selection, the IDR entity must select one of the
offers submitted and are required to choose
the offer closest to the QPA, unless additional
material information on a variety of different
subjects (e.g., market share in relation to the
relevant geographic region).
There is a lot to digest and care should be taken to
calendar each step. Creating a checklist with the
dates and response times is a good place to start. In
sum, there is little doubt that this federal IDR process
represents a significant change in the way out-ofnetwork
services are paid.
Be sure to watch the webinar by Rachel V. Rose called
The No Surprises Act – What You Need to Know.
C. Trey Scott, Coordinating Attorney at
COVID-19 Healthcare
Kennedy, Attorneys & Counselors at Law
will present Under Pressure: Reporting
Compliance
Appeals
Toolkit
for the Fifth Circuit.
Requirements with OCR for Breaches at the
upcoming Virtual HIPAA Privacy and Security
Summit 2021 Healthcare on November compliance 18. amidst COVID-19 Summit! presents new challenges
for hospitals and healthcare providers. At top importance is the
Trey received his Bachelor of Science and Master of
Business degrees
question
from Texas
of
Tech
how
University
to slow
and his
or stop the spread of COVID-19, while
ensuring that your organization stays compliant.
Juris Doctorate from Texas Wesleyan University School
of Law (now Texas A&M University School of Law.) While
in law school, Trey was Now a member more than of the ever, arbitration your compliance department needs to have the
necessary tools to help track, analyze, and respond to compliance challenges.
competition team as well as a student bar association
To help navigate the process, we’ve gathered our best COVID-19 resources
representative. He also was a law clerk to the 106th
below. If you need further assistance, please contact us here.
District Court of the State of Texas. Trey has significant
experience in healthcare law. This experience includes:
medical malpractice litigation, administrative and
regulatory appeals and disputes, professional board
VIEW TOOLKIT
United States District Courts for the Northern, Southern,
Eastern, and Western Districts of Texas. Trey is also
licensed to practice before the United States Court of
Click here for more information or to register for the
matters, and overpayment disputes. Trey is licensed to
practice law before Texas State Courts as well as the
Contact Toll Free: 888-54-FIRST 9

Q&A: Expanded Roles and Duties
for Medical Assistants during the
COVID-19 Era
Catherine Short
Donald A. Balasa, JD, MBA, CEO and Legal
Counsel at American Association of Medical
Assistants (AAMA), presented the webinar
“Expanded Roles and Duties for Medical
Assistants during the COVID-19 Era” on
April 13th. Mr. Balasa answered these
questions in anticipation of the webinar.
You mentioned that medical assistants can be
certified although not licensed in nearly every
state. How are you defining licensing and
certification?
Licensing is a mandatory, usually state, credential
without which an individual is prohibited legally from
working in a profession or occupation. Certification is
a voluntary credential, usually national in scope, that
is awarded by a private sector (usually) certifying body.
The CMA (AAMA) is a national certification for medical
assistants.
Are medical assistants permitted to perform
nasopharyngeal swabbing for COVID-19 testing?
Medical assistants are permitted to perform
nasopharyngeal swabbing for COVID-19 testing under
the laws of all states with the possible exception of
California. Medical assistants must be under the
authority and supervision of a licensed provider (e.g.,
physician, osteopath, nurse practitioner, physician
assistant) or a licensed health care professional (e.g.,
registered nurse) when performing nasopharyngeal
swabbing.
Do any federal agencies have a position on
medical assistants performing nasopharyngeal
swabbing?
The Centers for Medicare & Medicaid Services (CMS)
published an interim final rule with comment period
entitled “Medicare and Medicaid Programs; Policy and
Regulatory Revisions in Response to the COVID-19 Public
Health Emergency” (85 FR 19247 through 19253) in the
April 6, 2020, Federal Register. Its language supports my
legal position that medical assistants are permitted to
perform nasopharyngeal swabbing to test for COVID-19.
Note the following excerpts from this CMS rule:
Even if the patient is confined to the home because of a
suspected diagnosis of an infectious disease as part of a
pandemic event … a nasal or throat culture … could be
obtained by an appropriately-trained medical assistant or
laboratory technician. …
… Services furnished by auxiliary personnel (such as
nurses, medical assistants, or other clinical personnel
10
First Healthcare Compliance, LLC © 2022

acting under the supervision of the [rural health clinic]
or [federally qualified health center] practitioner) are
considered to be incident to the visit and are included in
the per-visit payment.
Are medical assistants permitted to administer
COVID-19 vaccinations?
Under the laws of most states, medical assistants are
permitted to administer COVID-19 vaccinations under
the authority and supervision of a licensed health care
provider or a licensed health care professional.
Do any federal agencies have a position on this?
Medical assistants are classified as “vaccinators” for
the COVID-19 vaccine under the COVID-19 Vaccination
Program. Read more in the COVID-19 Vaccination
Program Interim Playbook for Jurisdiction Operations
(2nd version) via the Centers for Disease Control and
Prevention (CDC) website.
What is the position of nursing organizations
on delegating the administration of COVID-19
vaccinations?
In its December 15, 2020, policy brief on COVID-19
vaccine administration, the National Council of State
Boards of Nursing—the membership organization for
boards of nursing in American jurisdictions—stated
that knowledgeable and competent “certified medical
assistants” may be delegated COVID-19 vaccine
administration.
Are medical assistants permitted to perform
telehealth tasks?
Medical assistants are permitted to perform telehealth
tasks as long as such tasks are within the scope of work
of the medical assistant in the state in which the medical
assistant is located.
Do any federal agencies have a position on
medical assistants in telehealth?
In a 2020 guidance on how to expand access to health
care during the COVID-19 pandemic, the Centers for
Disease Control and Prevention affirmed that medical
assistants and other health care professionals are
permitted to interact with patients by several means.
Note the following from this guidance:
COVID-19 Healthcare
Compliance Updates
In response to the global outbreak of the novel coronavirus
disease (COVID-19), the Secretary of Health and Human
Services declared a public health emergency on January 31,
2020. Federal agencies have taken action by issuing updates
and guidance to navigate the crisis. This ebook provides
healthcare providers with important developments and
resources that impact federal healthcare laws.
DOWNLOAD NOW
Contact Toll Free: 888-54-FIRST 11

Telehealth Modalities
Several telehealth modalities allow [health care
personnel] and patients to connect using technology to
deliver health care:
Synchronous: This includes real-time telephone or live
audio-video interaction typically with a patient using a
smartphone, tablet, or computer.
In some cases, peripheral medical equipment (e.g.,
digital stethoscopes, otoscopes, ultrasounds) can be
used by another HCP (e.g., nurse, medical assistant
[italics added]) physically with the patient, while
the consulting medical provider conducts a remote
evaluation.
Asynchronous: This includes “store and forward”
technology where messages, images, or data are
collected at one point in time and interpreted or
responded to later. Patient portals can facilitate this type
of communication between provider and patient through
secure messaging.
Remote patient monitoring: This allows direct
transmission of a patient’s clinical measurements from
a distance (may or may not be in real time) to their
healthcare provider.
Scope of practice resources:
AAMA website: www.aama-ntl.org
• Check the right column of the homepage for
COVID-19 updates.
• Click below “State Scope of Practice Laws” near
the left bottom of the homepage for the medical
assisting laws of all states.
• Put your cursor over “CMA Today” in the top
ribbon of the homepage; click on “Public Affairs
Articles” in the dropdown menu for articles from
2005 to the present.
• Click below “Legal Eye: On Medical Assisting” in
the left middle of the homepage for blog posts.
Note the following recent posts:
○
○
○
○
○
○
○
○
○
○
Clinical Task Delegation in Iowa
Medical Assistants in Ambulatory Surgery
Centers
CDC Affirms Medical Assistants’ Role in
Telehealth
Medical Assistants Answer the Call to Work in
Acute Care Settings
Testing Period Extension for the AUC Program
Suicide Safety Plan Delegation
New Jersey Prescription Monitoring Program:
Medical Assistants as Delegates
Permissible Delegation of Influenza Vaccination
Administration in Michigan
Permissible Medication Reconciliation by
Medical Assistants
The Delegation of Off-Site Blood Draws in
Washington
Donald A. Balasa, JD,
MBA, has served as CEO
and Legal Counsel of the
American Association of
Medical Assistants since
1990. Don received both
his baccalaureate and law
degrees from Northwestern
University and his MBA
in economics from the
University of Chicago. Mr. Balasa has taught courses
at the DePaul University Graduate School of Business
and Trinity International University. He can be reached at
dbalasa@aama-ntl.org
Be sure to view Don’s webinar here. Take a look at our
recent book: HIPAA Privacy and Security, and our online
compliance training courses such as What is HIPAA?, and
HIPAA Business Associate Agreements Under HITECH.
And check out Mr. Balasa’s other recordings and blogs
with us The Role of Medical Assistants in Medicare
CCM and TCM, Q&A: The Role of Medical Assistants in
Medicare CCM and TCM and an audio version of his
webinar found here.
12
First Healthcare Compliance, LLC © 2022

Referral Appreciation Program
Receive a $50 gift card* when you refer a client!
First Healthcare Compliance is delighted to offer
a Referral Appreciation Program to say thank you
for helping us to continue to grow. For each new
1st Professional or 1st Premium client originating
from a referral, First Healthcare Compliance will
provide a $50 gift card as a token of appreciation.
LEARN MORE
Healthcare
Compliance
Symposium
April 28, 2022
Registration will open soon.
Contact Toll Free: 888-54-FIRST 13

hosted by Catherine Short
Catherine Short speaks with Rachel V. Rose, JD, MBA, principal with Rachel V. Rose – Attorney at Law,
P.L.L.C., Houston, TX, on the topic of “The No Surprises Act – What You Need to Know.” Effective January
1, 2022, the No Surprises Act has implications for patients, providers, and insurance companies alike. The
impetus behind the legislation, as well as the regulations, is to prevent patients from receiving bills for certain
services that were performed or delivered by providers out of their plan’s network. The scope is limited and
providers and plans alike need to take steps to understand the appeal process when a payment or claim is
challenged. The purpose of this episode is to provide a brief overview of the evolution of the United States’
healthcare system and its relevance to the No Surprises Act. From there, the No Surprises Act and regulations
will be explained, along with the appeal process. Finally, compliance tips will round out the show.
Listen weekdays at
7:30am, 3:30pm, 11:30pm ET
Check out our Show Page!
Looking for the latest compliance insights?
Subscribe to our feed and don’t miss a thing!
14
First Healthcare Compliance, LLC © 2022

WORD SEARCH
U S U T X W S D X W G K N H T E N G M B
H T M R Y X C F T F X P X D I Y E U B O
B J I D N S U R P R I S E S C Q T Z R I
J X I W A G C F E C Q P A O B C W D P L
I G N A A Z B M Q D U R M V N I O F R J
G J D P H I K Y D F E P R G O W R J Z P
W S K P T I L B A C L N X K C J K R P R
N O I E L O S A H I N R T Q R V R J E O
J M B A A B C O A Q U E H I S A W E C V
H B U L E O I N F N I G I U A K Y E N I
W N Y H H Y C O K T L U Q Y R L I D A D
Z G Y K E E R S R Z W L B C A L P A D E
C G C T L A I Z E F U A C L N X A D I R
L S M W E K L B U D N T R E I X T E U S
E O E I T D Y T O D Q I S E B N I Y G L
B G D J G X Z L H G B O C B E K E V U V
P Z I Y A E D N M C P N X A W Z N B V N
Q N C M B Y T E B R A S J F D F T P R Q
R D A G J G O U U B R R H Z C X S S Z A
V P L C B B K P I F I W E N H D J Y J N
SURPRISES REGULATIONS PATIENTS
NETWORK PROVIDERS PURPOSE
HEALTHCARE APPEAL COMPLIANCE
SOFTWARE WEBINAR CREDENTIAL
MEDICAL TELEHEALTH GUIDANCE
Contact Toll Free: 888-54-FIRST 15

Upcoming and On-Demand Webinars
Training
JAN 25, 2021
Hardware Hacking Trends - The Insecurity of Everything
Register
FEB 16, 2021 Employment and Labor Law Round-up With 2022
Forecast and Other HOT Topics
Register
ON DEMAND
ON DEMAND
ON DEMAND
The No Surprises Act - What You Need to Know
AUC – Delayed but not Gone
Recent Developments in Health Information Privacy:
HIPAA Right of Access, NPRM, & Information Blocking
All Upcoming Webinars
All On Demand Webinars
IMPORTANT
In the interest of your security, login credentials are
for individual use only and not to be shared. Please
contact Client Services if you require additional
manager level users and/or if there has been a
change in contact information.
NEW FEATURES!
HIPAA Zone - New Documents and Updated
Policies are available in the HIPAA Zone Resources
Tab
CLIENT
Great News! You can now
ALERT
customize and Manage Zone access
for your Account / Client Dashboards
as well as for your Managers and Supervisors.
Contact Client Services for details.
Employee Zone/Compliance Detail
Initial Data - Free text comment field has been
added.
COVID Vaccination Status/ COVID Testing -
Additional fields have been added to assist you
with tracking COVID vaccination and COVID Testing.
Contact Client Services if you have any questions or
would like to turn COVID alerting off.
Join us on Social Media!
Contact our Client Services Team with your questions!
888.54.FIRST or clientservices@1sthcc.com
16
First Healthcare Compliance, LLC © 2022