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Management Services Organization (MSO)

Empassion Health Compliance

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Empassion Health is committed to being an ethical corporate citizen.

We hold our associates and ACO partners to high standards of integrity, and conduct business in compliance with federal, state, and local laws and regulations. 

Under the terms of both the Implementation Period (IP3) and the Model Performance Period (MPP) Participation Agreements, Empassion has implemented a monitoring plan, for each ACO, that is designed to protect beneficiaries and address potential ACO REACH program integrity risks.

Compliance Officer

The Chief Compliance Officer does not serve as legal counsel to Empassion or its ACOs and reports directly to the governing body of the REACH ACO, and to the Chief Executive Officer, Robin Heffernan, within the Empassion Health MSO.

Identifying and Addressing Noncompliance

Empassion and its ACO partners, including its employees and contractors, have a responsibility to promptly report any suspected incidents regarding potential violations of the REACH Agreements and/or state or federal laws.

Through proper education of compliance standards and issues across the leadership team, governing body, and Participant and Preferred providers, Empassion will train associates on how to become vigilant to potential instances of noncompliance. 

All concerns and questions should be directed to the Chief Compliance Officer, who is responsible for documenting, escalating to the governing body, and responding to the question. The Compliance Officer will track compliance questions and concerns for each ACO to ensure rectification, and report on key performance measures to the governing body quarterly.

Anonymous Reporting

There is no retribution for reporting credible instances of improper or unlawful conduct.

Anonymous reporting may be made to the Chief Compliance Officer through a hotline and online submission form to be established by the ACO. All ACO providers, employees, contractors, and beneficiaries are aware of the anonymous compliance hotline and submission form upon joining the ACO or voluntary aligning to the ACO.

Training and Education

All ACO Participant and Preferred Providers, employees, and contractors must complete compliance training upon joining the ACO, at hire and annually, to ensure that all parties are kept up to date on compliance and program requirements. 

Completion of such training will be confirmed through a signed attestation that will be maintained by the Chief Compliance Officer in the ACO’s records.

Reporting to Authorities

The ACO is required to report violations and probable violations to an appropriate law enforcement agency. 

The Chief Compliance Officer will be responsible for working with the governing body, CMS, and relevant law enforcement agencies to determine whether compliance issues may be “probable violations of law”. The Chief Compliance Officer will bring expertise on relevant laws, regulations, and CMS/CMMI requirements to inform such decisions.

The purpose of the Incident Report form is to allow you to report suspicions of ACO REACH Program noncompliance or unlawful activities timely, efficiently and (should you prefer) anonymously.


You may report suspicions of ACO REACH Program noncompliance or unlawful activities via the following email address or phone number:



You may also submit a report online. If you prefer, online reports may be submitted anonymously.

Our ACOs

You can find contact information or report potential noncompliance for each of our ACOs on the following pages:


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