This article was written by Amy Mowles, president and CEO of Mowles Medical Practice Management, LLC, in Edgewater, Md.
Office-based surgery accreditation:
Twenty-six state health departments plus D.C. have jurisdiction on office based surgery meeting various thresholds. The most common specialties performing office based surgery are pain management, plastic surgery and GI.
The requirement is typically based on the levels of anesthesia used and/or complexity of procedure performed. For instance, New York and Pennsylvania refer to pain management as "invasive and complex" regardless of whether anesthesia or moderate sedation is used with the procedure.
The twenty-six health departments include Alabama, Arizona, California, Colorado, Connecticut, DC, Florida, Illinois, Indiana, Kansas, Kentucky, Louisiana, Massachusetts, Mississippi, Nevada, New Jersey, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Virginia and Washington. Delaware will implement by the end of 2012.
Accreditation by a third party is the most typical way of satisfying the office based surgery state regulation. A few states however, require their own survey. In either case, both the state regulations and the accreditation standards will have governance.
Q: Once accredited, can I bill facility fees?
A: Office-based accreditation is NOT an avenue to receive facility fees. Local and state law, and third party payer policies (commercial and workers' comp) typically require the facility to be licensed and certified in order for facility fees to be paid. There have been cases of what the prosecution labeled as wire and mail fraud for billing facility fees outside of the ASC program. Insurance companies have also visited office-based surgery practices in an attempt to show a scheme to defraud the insurance company.
Q: I see the Medicare standards listed in the accreditation manual. Does that apply since our office based surgery practice treats Medicare beneficiaries?
A: No. CMS is the authority having jurisdiction for ambulatory surgery centers only. CMS does not govern office-based surgery. The standards shown in accreditation manuals are for those ASCs seeking deemed status Medicare surveys from the accreditation body. The Medicare conditions of participation, also known as the state operation manual, are regulations that all ASCs must meet in order to be recommended for participation in the Medicare program as a provider of surgical services (certification).
Q. How would my state know if I am accredited by a third party?
A: Many states require a registration, license or even a state certification for office based surgery. Some require the accreditation results to be filed with them. Some publish their office-based surgical practices with survey results on their website.
In states that do not show how they have jurisdiction, it becomes one's own tolerance for risk. A disgruntled employee or patient can file a grievance.
Q: Are their design requirements for office-based surgery practices?
A: Not from a standpoint of Medicare Life Safety Code (NFPA) or ASC license, such as AIA guidelines. Accreditation typically speaks to Accepted Standards of Care – "safe and appropriate" (implied risk control). Accreditation bodies vary in their physical environment regulations but again, it is specific to the types of procedures and level of anesthesia.
Physical environment that does apply for office-based surgery practices include:
Local building codes -- number of exits, widths of exits
Zoning ordinances – parking, setbacks, height & area limitations, landscaping
Plumbing codes -- required toilets, etc.
HIPPA -- privacy by design
Americans with Disabilities Act
State & city-specific requirements
In all cases, surveyors would expect to see reasonable separation of unrelated tasks and certainly clean and soiled work rooms.
Q. Why accreditation for office-based surgery?
A.
1. Often fulfills state requirements for office based surgery.
2. Expedites third-party payment.
3. May favorably influence liability insurance premiums.
4. Favorably influences managed care contract decisions.
5. Enhances community confidence.
6. Aids in professional staff recruitment.
Ambulatory surgery center accreditation:
The vast majority of commercial payors require accreditation (above and beyond state license, as applicable, and always Medicare certification) in order for the ASC to become a participating provider with their network. Documentation as proof must be submitted with the ancillary application before the request for ASC participation will even go through the company's credentialing process.
Q. What is deemed status?
A: In order for a healthcare organization to participate in and receive payment from the Medicare or Medicaid programs, it must meet the eligibility requirements for program participation, including a certification of compliance with the Conditions of Participation (or Conditions for Coverage, CfCs, for health care suppliers) set forth in federal regulations. This certification is based on a survey conducted by a state agency on behalf of the Centers for Medicare & Medicaid Services.
However, if the state will not provide initial or ongoing Medicare surveys, using a national accrediting organization is the answer. They have and enforce standards that meet or exceed Medicare's CoPs (or CfCs). CMS grants accrediting organization "deeming" authority. Note that state departments of health have been given the guidance from CMS to put ASC surveys for Medicare on a non-emergent basis.
For most types of healthcare providers or suppliers, accreditation is voluntary and seeking deemed status through accreditation is an option, not a requirement.
Seeking a Medicare certification survey through an accreditation organization for purposes of Medicare certification, however, is not an option … that is, if the ASC wants facility fees!
Q: Who is responsible for Medicare surveys?
A: Whoever did the initial survey is responsible unless told otherwise. For instance, if the state did the initial survey but an accreditation organization did just the accreditation, you would not have to ask the organization for another Medicare survey.
On the other hand, if the accreditation organization was asked to perform the initial Medicare survey, not requesting it on the next accreditation cycle, would indicate that the ASC was dropping their participation and the state would be notified. This would prompt a survey from the state.
Resources:
ο Accreditation Association for Ambulatory Health Care
ο Joint Commission on Accreditation of Healthcare Organizations
ο American Association for Accreditation of Ambulatory Surgery Facilities
Office-based surgery accreditation:
Twenty-six state health departments plus D.C. have jurisdiction on office based surgery meeting various thresholds. The most common specialties performing office based surgery are pain management, plastic surgery and GI.
The requirement is typically based on the levels of anesthesia used and/or complexity of procedure performed. For instance, New York and Pennsylvania refer to pain management as "invasive and complex" regardless of whether anesthesia or moderate sedation is used with the procedure.
The twenty-six health departments include Alabama, Arizona, California, Colorado, Connecticut, DC, Florida, Illinois, Indiana, Kansas, Kentucky, Louisiana, Massachusetts, Mississippi, Nevada, New Jersey, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Virginia and Washington. Delaware will implement by the end of 2012.
Accreditation by a third party is the most typical way of satisfying the office based surgery state regulation. A few states however, require their own survey. In either case, both the state regulations and the accreditation standards will have governance.
Frequently asked questions:
Q: Once accredited, can I bill facility fees?
A: Office-based accreditation is NOT an avenue to receive facility fees. Local and state law, and third party payer policies (commercial and workers' comp) typically require the facility to be licensed and certified in order for facility fees to be paid. There have been cases of what the prosecution labeled as wire and mail fraud for billing facility fees outside of the ASC program. Insurance companies have also visited office-based surgery practices in an attempt to show a scheme to defraud the insurance company.
Q: I see the Medicare standards listed in the accreditation manual. Does that apply since our office based surgery practice treats Medicare beneficiaries?
A: No. CMS is the authority having jurisdiction for ambulatory surgery centers only. CMS does not govern office-based surgery. The standards shown in accreditation manuals are for those ASCs seeking deemed status Medicare surveys from the accreditation body. The Medicare conditions of participation, also known as the state operation manual, are regulations that all ASCs must meet in order to be recommended for participation in the Medicare program as a provider of surgical services (certification).
Q. How would my state know if I am accredited by a third party?
A: Many states require a registration, license or even a state certification for office based surgery. Some require the accreditation results to be filed with them. Some publish their office-based surgical practices with survey results on their website.
In states that do not show how they have jurisdiction, it becomes one's own tolerance for risk. A disgruntled employee or patient can file a grievance.
Q: Are their design requirements for office-based surgery practices?
A: Not from a standpoint of Medicare Life Safety Code (NFPA) or ASC license, such as AIA guidelines. Accreditation typically speaks to Accepted Standards of Care – "safe and appropriate" (implied risk control). Accreditation bodies vary in their physical environment regulations but again, it is specific to the types of procedures and level of anesthesia.
Physical environment that does apply for office-based surgery practices include:
Local building codes -- number of exits, widths of exits
Zoning ordinances – parking, setbacks, height & area limitations, landscaping
Plumbing codes -- required toilets, etc.
HIPPA -- privacy by design
- Checkout separation
- Personal space in waiting rooms
- Door swings
- Sight-lines & patient orientation -- perception is 90 percent of reality
- Radiation safety varies significantly by state
- "Soundproof"
Americans with Disabilities Act
State & city-specific requirements
In all cases, surveyors would expect to see reasonable separation of unrelated tasks and certainly clean and soiled work rooms.
Q. Why accreditation for office-based surgery?
A.
1. Often fulfills state requirements for office based surgery.
2. Expedites third-party payment.
3. May favorably influence liability insurance premiums.
4. Favorably influences managed care contract decisions.
5. Enhances community confidence.
6. Aids in professional staff recruitment.
Ambulatory surgery center accreditation:
The vast majority of commercial payors require accreditation (above and beyond state license, as applicable, and always Medicare certification) in order for the ASC to become a participating provider with their network. Documentation as proof must be submitted with the ancillary application before the request for ASC participation will even go through the company's credentialing process.
Q. What is deemed status?
A: In order for a healthcare organization to participate in and receive payment from the Medicare or Medicaid programs, it must meet the eligibility requirements for program participation, including a certification of compliance with the Conditions of Participation (or Conditions for Coverage, CfCs, for health care suppliers) set forth in federal regulations. This certification is based on a survey conducted by a state agency on behalf of the Centers for Medicare & Medicaid Services.
However, if the state will not provide initial or ongoing Medicare surveys, using a national accrediting organization is the answer. They have and enforce standards that meet or exceed Medicare's CoPs (or CfCs). CMS grants accrediting organization "deeming" authority. Note that state departments of health have been given the guidance from CMS to put ASC surveys for Medicare on a non-emergent basis.
For most types of healthcare providers or suppliers, accreditation is voluntary and seeking deemed status through accreditation is an option, not a requirement.
Seeking a Medicare certification survey through an accreditation organization for purposes of Medicare certification, however, is not an option … that is, if the ASC wants facility fees!
Q: Who is responsible for Medicare surveys?
A: Whoever did the initial survey is responsible unless told otherwise. For instance, if the state did the initial survey but an accreditation organization did just the accreditation, you would not have to ask the organization for another Medicare survey.
On the other hand, if the accreditation organization was asked to perform the initial Medicare survey, not requesting it on the next accreditation cycle, would indicate that the ASC was dropping their participation and the state would be notified. This would prompt a survey from the state.
Resources:
ο Accreditation Association for Ambulatory Health Care
ο Joint Commission on Accreditation of Healthcare Organizations
ο American Association for Accreditation of Ambulatory Surgery Facilities