General Information
Choosing the Deemed Status Option
CMS Information
Joint Commission Deemed Status Process
Standards Information
In 1996, the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) announced that ambulatory surgical centers accredited by the Joint commission would be "deemed" as meeting or exceeding Medicare certification requirements. This information has been developed to answer common questions about deemed status.
General Information
What is Deemed Status?
Ambulatory Surgery Centers (ASCs) wishing to receive Medicare or Medicaid reimbursement must be certified as complying with the conditions for coverage (CFCs) set forth in the federal regulations developed by CMS (see below for a description of CFCs). When a national accrediting organization, such as the Joint Commission, provides CMS with verification that the organizations it accredits meet or exceed the federal conditions, including conditions for coverage, CMS has agreed to deem the organizations as meeting the Medicare and Medicaid certification requirements, provided that certain survey requirements are met (e.g., the accreditation survey must be unannounced.) A Joint Commission accredited ASC thus qualifies for deemed status and may not be required to undergo a separate certification inspection performed on behalf of CMS.
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What is the difference between accreditation, certification, and licensure?
The terms accreditation, certification, and licensure are often assumed to mean the same thing when, in fact, they have distinct definitions. For example, an ambulatory surgery center that is licensed and certified, may not be accredited; and one that is accredited, is not necessarily CMS certified. Following are specific definitions for each term:
Accreditation: A formal and voluntary process by which an independent body assesses and recognizes an organization as meeting or exceeding criteria. For example, accreditation by the Joint Commission is a determination that an eligible health care organization complies with applicable standards related to issues like patient safety.
Certification: The procedure and action by which CMS evaluates and recognizes (certifies) an institution that has met all requirements for participation in the Medicare program requirements or conditions.
Licensure: Authorization by law (usually at the state level) to perform the activities of a profession (such as medicine, dentistry, or nursing) or the operation of a facility (such as a hospital or ambulatory surgery center).
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Does deemed status mean that accreditation is now mandatory for ASCs wishing to receive Medicare reimbursement?
No. The decision to seek accreditation, as well as the decision to use the Joint Commission's survey for Medicare certification purposes, is voluntary. Deemed status is offered as an option to those ASCs wishing to elect it.
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Does electing the deemed status option eliminate the requirement for state licensure surveys that may also exist?
No. The deemed status option refers only to CMS certification (which is federal) and does not eliminate the requirement for state licensure surveys. However, some states recognize Joint Commission accreditation in lieu of performing their own routine state licensure inspections; thereby eliminating the need for an ASC to have both an accreditation survey and a state licensure survey. Other states have expressed interest in pursuing such an approach. ASCs should contact the appropriate state agency for further information regarding state recognition of accreditation and licensure requirements.
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Our ASC is already accredited, does that mean we automatically have deemed status with CMS?
No. If your ASC is not already certified by CMS, you will need to have a CMS certification inspection and to obtain a provider number from your state surveying agency. The use of Joint Commission accreditation for Medicare certification purposes is available only on the basis of unannounced surveys that are conducted with specific assessment of compliance with the CMS conditions for coverage.
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Choosing the Deemed Status Option
Are there differences between a Joint Commission accreditation survey and a Joint Commission accreditation with deemed status survey?
Although the majority of the survey processes and standards reviewed are similar, there are two important distinctions. First, if your ASC is seeking deemed status, the survey will be unannounced, as required by CMS. After the Joint Commission receives the ASC's completed application, the survey will be scheduled; however, the ASC will not be informed in advance of the dates that the survey will take place.
Second, the survey will be conducted to evaluate compliance with both Joint Commission standards and CMS Conditions for Coverage; however, no additional survey days, surveyors, or fees are required. Once the Joint Commission compiles the survey results, it sends an Official Accreditation Report to the ASC, with copies to CMS, the CMS regional office, and the state.
Third, the Statement of Conditions must be completed for all deemed status surveys. The Statement of Conditions is a document that helps an organization do a critical self-assessment of its current level of compliance with the Life Safety Code, and describe how to resolve any deficiencies.
After the ASC becomes accredited under the Joint Commission accreditation process, it must notify its applicable state agency (SA) of its desire to participate in the Medicare program. The SA will provide a certification kit containing:
- Form HCFA-370, Health Insurance Benefit Agreement; and
- Form HCFA-377, ASC Request to Establish Eligibility in the Medicare and Medicaid program.
Once the forms are submitted, CMS will issue a Medicare provider number.
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Does the deemed status survey option cost more?
Choosing the deemed status option does not increase your survey fee.
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Can a new ASC elect the deemed status option for its initial certification survey?
Yes. As long as the surgery center meets the CMS requirements and conditions for coverage, the ASC can request the deemed status option when submitting its application for survey. An unannounced survey will then be conducted to evaluate compliance with both Joint Commission ambulatory care standards and CMS conditions for coverage. Once the final accreditation decision is made, the ASC can submit its accreditation award letter to the state survey agency to receive a provider number.
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We've been certified by Medicare but have never been accredited, how can we take advantage of the deemed status option?
When you complete your request for survey, indicate your desire for a deemed status survey on the application. Then, using your accreditation award letter, notify your state survey agency that you intend to use the deemed status option with the Joint Commission for future recertification activity.
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Our ASC is already accredited by the Joint Commission and certified by Medicare, can we select Joint Commission in lieu of future Medicare certification surveys?
Yes. Indicate your desire for a deemed status survey when you next complete an application for resurvey. The SA will remove your ASC from its survey schedule once you send a copy of the accreditation letter to the SA. The CMS regional office (RO) will amend its records to reflect the accreditation status of the ASC.
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How does an ASC notify the Joint Commission and CMS that it wishes to elect the deemed status option?
An ASC must notify the appropriate state survey agency that it intends to elect the deemed status option by the Joint Commission. (List of state survey agencies) When completing the Joint Commission's Request for Survey, the ASC should select the ASC deemed status survey option.
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Does electing the deemed status option alter the length of the accreditation survey for both accreditation and certification purposes?
No. A typical survey of an ambulatory surgery center takes about two days. Because there is significant overlap between Joint Commission standards and the CMS Conditions for Coverage, these requirements can be assessed in the same time frame as a regular ambulatory care accreditation survey.
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CMS Information
How does CMS define an ambulatory surgery center?
CMS has a specific definition for ambulatory surgery centers eligible to receive reimbursement for facility services from Medicare and/or Medicaid:
An ambulatory surgical center or ASC means any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization, has an agreement with CMS to participate in Medicare as an ASC, and meets the conditions set forth [below].
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What are the Conditions for Coverage and where can I find them?
Conditions for Coverage (CFCs) are the conditions that an ASC must meet in order to participate in the Medicare program.
There are ten general areas covered by Conditions for Coverage. Each of the ten areas includes specific standards or requirements that must be met by the ambulatory surgery center. The ten general areas are:
- Compliance with State Licensure Law
- Governing Body and Management
- Surgical Services
- Evaluation of Quality
- Environment
- Medical Staff
- Nursing Services
- Medical Records
- Pharmaceutical Services
- Laboratory and Radiologic Services
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How will CMS and the public know that an accredited ASC has elected the deemed status option?
An ASC that undergoes an unannounced survey by the Joint Commission for certification purposes receives a separate award letter regarding the Medicare survey findings. This information is also shared with CMS, and with the public upon request.
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How does CMS monitor the Joint Commission to assure that agreed-upon procedures are followed?
CMS reserves the right to conduct a sampling of validation surveys for those ASCs electing the deemed status option. CMS may also monitor Joint Commission internal procedures, such as surveyor training and management or the decision making process.
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Joint Commission Deemed Status Process
We have a very small setting, with comparatively small annual patient volume. Is our setting appropriate for accreditation from the Joint Commission?
Absolutely. Our standards and survey process are highly adaptable to a wide range of settings. Over 40% of the free-standing ambulatory care provider settings that we accredit report fewer than 5,000 patient visits each year. Of these settings, more than 60% reported annual visits of under 2,500.
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If our ASC has applied for the deemed status option, how will patients and staff be notified of the availability of a Public Information Interview during the unannounced accreditation survey?
Although the notification to patients and staff of the availability of a Public Information Interview cannot include the date of the survey, ASCs are still expected to notify patients and staff within a reasonable time frame of when the accreditation survey is due. Interested patients and staff notify the Joint Commission directly of their desire for a Public Information Interview. The Joint Commission then notifies the surveyor who arranges for the interview during the on-site survey.
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How long does it take to get scheduled for survey?
Your survey will typically be scheduled within 60 - 90 days after receiving your request for survey. In some instances, when surveyor time is available, we can schedule the survey sooner if you would like. Often, organizations will submit their application four to six months ahead of their desired date of survey so that they'll have the best chance of being scheduled exactly when they want.
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How does the Joint Commission determine whether a condition for coverage is met during a deemed status survey?
The Joint Commission surveyor uses both applicable standards and scoring guidelines to evaluate organizational compliance with the standards. Each standard is scored using a three-point scoring scale. Joint Commission central office staff analyze the surveyor's findings and use predetermined aggregation and decision rules to ensure a consistent, valid, and reliable decision. The organization receives a written report of the survey findings, including any requirements for improvement where the conditions for coverage were not substantially met.
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Can the Joint Commission institute sanctions or decertify an agency under the deemed status option?
No. The Joint Commission submits its survey findings to CMS. Only CMS or a state agency can implement any necessary Medicare corrective actions or alternative sanctions (e.g., fines or suspension of Medicare payments). CMS or the state agency may wish to conduct its own survey if the findings of the Joint Commission survey indicate a serious concern, and apply sanctions accordingly.
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I would like more information about Joint Commission accreditation of ambulatory surgery centers. Who should I contact?
There are a number of resources available at the Joint Commission to help you learn about accreditation and to assist you in preparing for survey. For general questions about accreditation, call the Ambulatory Care Accreditation Program at (630) 792-5286. If you have questions about educational programs designed to help you get ready for survey, call our Customer Service Center at (630) 792-5800. If you have questions about interpretation of standards, call the Standards Interpretation Unit at (630) 792-5900. If you have questions about state recognition of accreditation, call our State Relations Office at (630) 792-5261.
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Standards Information
What are the areas encompassed by the accreditation standards and survey process?
Our standards and survey process cover critical areas related to patient care, patient safety, and organizational functions. The following table shows the titles and general areas that are included in these critical functions. The on-site survey traces actual patient files through the organization to assess compliance with the standards.
The Nine Functional Chapters of the Accreditation Manual for Ambulatory Care
|
Patient Focused Functions |
Organization Functions |
|
· Ethics Rights and Responsibilities |
· Improving Organization Performance |
|
· Provision of Care, Treatment and Services |
· Leadership |
|
· Medication Management |
· Management of the Environment of Care |
|
· Surveillance, Prevention and Control of Infection |
· Management of Human Resources |
|
|
· Management of Information |
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How can I obtain a copy of the standards?
The standards are found in the Comprehensive Accreditation Manual for Ambulatory Care. Once the Joint Commission has received your request for survey, you will receive a copy of the accreditation manual. Accredited ambulatory care organizations also receive complimentary copies of all new editions of the manual. At any time you can order additional copies of the manual for $240 each by calling Joint Commission Customer Service at (877) 223-6866, or by visiting the Joint Commission Resources web site at www.jcrinc.com.
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