As previously communicated in Perspectives October 2009, effective July 15, 2010, The Joint Commission will begin to accredit hospitals in accordance with their Centers for Medicare and Medicaid Services Certification Number (CCN). Over the last several months, Joint Commission staff has contacted organizations impacted by this change. We have developed several key Frequently Asked Questions (FAQs) which should answer many of the questions you may have about this change.
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In accordance with the hospital deeming authority granted by the Centers for Medicare and Medicaid Services (CMS), effective July 15, 2010, Joint Commission will be required to accredit hospitals in accordance with their CMS’ Certification Number (CCN), formerly known as the Medicare Provider Number. This means that there must be a one-to-one match between a Joint Commission accreditation award and a hospital CCN; that is, a single accreditation award cannot encompass more than one single CCN or one single CCN cannot encompass more than one accreditation decision.
Historically, almost all of the hospitals accredited by the Joint Commission have been accredited in accordance with their CCN. However, less than 100 hospitals--for a variety of reasons--have not. The Joint Commission has been working with the hospitals on a one-on-one basis to help with the transition.
The following are relevant FAQs and answers.
What is a hospital’s CCN?
A hospital’s CMS’ Certification Number (CCN), is the hospital’s identification number and is linked to its Medicare provider agreement. The CCN is used for CMS certification. Certain types of health care facilities, including hospitals, seeking to participate in the Medicare program are required not only to satisfactorily complete the Medicare enrollment application, but also to be certified as meeting the Medicare health and safety standards. The CCN is also used for submitting and reviewing the hospital’s cost reports. The CCN number used to be called the "provider number," but with the advent of the statutorily mandated National Provider Identifier (NPI) number for claims processing, the CCN now plays a different role within the Medicare program.
How does a hospital get a CCN?
A hospital that seeks to participate in the Medicare program must first submit Form CMS 855A, Medicare Enrollment Application for Institutional Providers, to its regional Medicare Administrative Contractor or legacy Fiscal Intermediary. Once the application is reviewed by the MAC/FI and recommended for approval to the CMS Regional Office, the hospital must then demonstrate its compliance with the Hospital Conditions of Participation through a survey, and, in the case of specialized hospitals, with other Federal requirements as well. Once it has demonstrated this, the CMS Regional Office will assign an effective date for the Medicare provider agreement and issue the CCN. Even if the hospital changes ownership, it will retain the same CCN, so long as the new owners assume the Medicare provider agreement. However, there are circumstances when an existing hospital that has participated in Medicare must be treated as a new provider, undergoing a new enrollment process and assignment of a new CCN. The CMS determines the requirements and process governing the enrollment of a hospital in Medicare and assignment of a CCN. Additionally, CMS will change the CCN if the hospital changes its type of Medicare hospital classification, such as when a short term acute care hospital converts to a Long Term Care Hospital.
Will the Joint Commission be required to determine if a "hospital" seeking accreditation for Medicare certification matches the way in which that hospital is enrolled in Medicare?
Yes, the Joint Commission changed its eligibility criteria to specifically require that only "hospitals" that match the way in which they are enrolled in the Medicare program can be surveyed as one hospital using Joint Commission hospital standards.
The Medicare program allows considerable flexibility to hospital systems to define the "boundaries" of a participating hospital. As an example, a system that owns four "hospitals" in a specified geographic area may choose to have each hospital separately enrolled in Medicare, or, if it satisfies applicable Medicare rules, it can enroll them as one multi-campus hospital. In the first instance, each of the four hospitals would have its own CCN, and each would be required to comply separately with the CoPs. In the second instance, the four facilities would each be campuses of one hospital with one CCN, and together they would have to comply with the CoPs as one hospital. The hospital system, not the CMS, makes the decision on the manner in which it enrolls the facilities, but once it has done so, it must be surveyed and accredited in the same manner.
Is the requirement for the Joint Commission to accredit hospitals in accordance with their CCN a new requirement from CMS?
In July 2008, a new law was passed which required Joint Commission to apply for continued deeming authority. This continued deeming authority was awarded, and published in the Federal Register on November 29, 2009. As part of this award, effective July 15, 2010, Joint Commission will be required to accredit hospitals in accordance with their CCN.
Why is CMS requiring Joint Commission to accredit hospitals in accordance with their CCN?
The CMS identifies the boundaries of a hospital in terms of what locations it has identified on its Form CMS 855A application (including all subsequent 855As submitted with location updates); all of these locations are covered under the same CCN associated with this application. Therefore, the compliance of a hospital, as measured by an accreditation award, must be assessed in accordance with the CCN. When there is not a one-to-one match between an accreditation award and a CCN, noncompliance with the CoPs is likely. For example, when a hospital participates in Medicare as a multi-campus hospital with four inpatient locations, it must have one governing body, and one unified medical and nursing staff for all campuses. Medicare regulations do not permit independent compliance with the CoPs at separate locations of a hospital. Further, serious non-compliance at any one campus impacts the participation of all campuses in Medicare since they participate as only one hospital. If at the same time it is accredited as four separate hospitals, then each campus would separately meet the accreditation standards, which is inconsistent with the Medicare requirements.
Is CMS requiring AOA and DNV to accredit hospitals in accordance with their CCN?
Yes, all hospital accreditors granted deeming authority by the CMS are required to accredit hospitals in accordance with their CCN.
For the hospitals that have not been accredited in accordance with their CCN, will this requirement impact them significantly?
It depends, and each situation may be different. In order for a hospital to be Medicare-certified and assigned a CCN and also be accredited, it must be able to demonstrate that it meets all of the Conditions of Participation (CoPs), and Joint Commission standards in addition to the CoPs, at all locations covered by the CCN, but independent of any other hospital facilities not covered by that CCN. For hospitals that have participated separately in Medicare, but have been accredited as one multi-campus facility, the governing body and medical staff requirements may be problematic, since in the past a single governing body and a single medical staff may have been responsible for multiple hospitals. Going forward, each entity that has chosen to participate in Medicare as one hospital must have a single governing body and a single medical staff. Conversely, each hospital system that has chosen to have each hospital participate separately in Medicare but has been accredited as one entity must have separate governing bodies, medical staffs and nursing staffs, even if this is duplicative within their multi-hospital system. For the impacted hospitals, Joint Commission will discuss their circumstances and share suggested approaches.
Can the same individuals who make up the governing body and/or the same individuals who make up the medical staff be responsible for more than one hospital?
Yes, as long as the responsibilities for each hospital’s governing body and medical staff are performed independent of carrying out responsibilities for another hospital, and there is evidence of such. For example, the same set of individuals may function as the governing body or medical staff for more than one hospital, but they must convene themselves separately as each hospital’s governing body or medical staff in order to carry out their responsibilities for each separately certified hospital. The separation does not have to be by place, but by time – in other words, the same individuals can meet in one place, convene themselves as the governing body of Hospital A, conclude their business, and then convene themselves as the governing body of Hospital B, etc. Each meeting must have its own set of minutes, etc. Further, with respect to the medical staff, there needs to be a separate privileging process for each hospital, even though the same physicians may practice at both hospitals.
Does a hospital or a hospital system need to do restructuring so that each hospital is accredited in accordance with their CCN?
To the degree possible, we would hope not. Through the years, hospitals have formed "systems" to standardize and integrate their services to improve their delivery of patient care; we wouldn’t want to interfere with this positive effort. Nonetheless, each facility in a "system" which has enrolled separately in Medicare and has its own CCN must be able to demonstrate compliance with the CoPs independent of other hospitals in the "system." Joint Commission staff will work with each affected hospital/"system" to help them understand the requirements and any actions they may wish to pursue to be in compliance. Hospital systems also have the option of changing the way in which their member facilities are enrolled in Medicare, in order to match they way in which they are accredited. Such decisions may have complex ramifications, for example in terms of the number of Medicare graduate medical education slots available to the system. Hospital systems, therefore, should carefully consider what arrangement best serves their needs. For specific questions about changing enrollment in Medicare, it is recommended that the organization contact their CMS Regional Office to discuss the potential ramifications of any such changes.
Besides assuring that each hospital is in compliance with the CoPs and Joint Commission standards independent of any other hospital, are there any other relevant changes related to accrediting hospitals in accordance with their CCN?
Yes, all locations covered by a hospital’s CCN are subject to survey for compliance with the hospital standards . This is because the hospital has indicated in its Form 855A filings to CMS that all of these service locations are hospital departments/services, and therefore, they must be able to meet the hospital CoPs. Thus, if a hospital identifies ambulatory care services and/or behavioral health care services on its Form 855A as a provider-based hospital department, (regardless of whether these services are on the main hospital campus or off-site), or as a remote (i.e. inpatient) location or satellite, then these services must be surveyed as part of the one accredited hospital, using hospital standards. If Joint Commission policies specify another set of standards, such as ambulatory or behavioral health care to survey these services, then these standards will be used in addition to the hospital standards. On the other hand, if a service/program (e.g. home care or ambulatory) has a separate CCN, the service/program cannot be surveyed as part of the hospital, but would instead be surveyed using home care or ambulatory health care standards, respectively.
Will all "provider-based" departments, satellites or remote locations under a hospital’s CCN be included in the hospital’s survey?
Yes, all "provider-based departments," provider-based remote locations" and "satellites" of a provider covered under a hospital’s CCN will be subject to inclusion in the hospital’s survey. The following definitions from the CMS regulations may help to clarify
- "Department of a provider means a facility or organization that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of the same type as those furnished by the main provider under the name, ownership, and financial and administrative control of the main provider, in accordance with the provisions of this section. A department of a provider comprises both the specific physical facility that serves as the site of services of a type for which payment could be claimed under the Medicare or Medicaid program, and the personnel and equipment needed to deliver the services at that facility. A department of a provider may not by itself be qualified to participate in Medicare as a provider under §489.2 of this chapter, and the Medicare conditions of participation do not apply to a department as an independent entity. For purposes of this part, the term "department of a provider" does not include an RHC or, except as specified in paragraph (n) of this section, an FQHC." Provider-based departments do not include those that perform functions necessary for the successful operation of the providers but do not furnish services of a type for which separate payment could be claimed under Medicare or Medicaid.
- "Remote location of a hospital means a facility or an organization that is either created by, or acquired by, a hospital that is a main provider for the purpose of furnishing inpatient hospital services under the name, ownership, and financial and administrative control of the main provider, in accordance with the provisions of this section. A remote location of a hospital comprises both the specific physical facility that serves as the site of services for which separate payment could be claimed under the Medicare or Medicaid program, and the personnel and equipment needed to deliver the services at that facility. The Medicare conditions of participation do not apply to a remote location of a hospital as an independent entity. For purposes of this part, the term "remote location of a hospital" does not include a satellite facility. . ."
- "Satellite facility is a part of a hospital that provides inpatient services in a building also used by another hospital, or in one or more entire buildings located on the same campus as buildings used by another hospital, or in one or more entire buildings located on the same campus as buildings used by another hospital." Satellites are part of an Inpatient Prospective Payment System (IPPS)-excluded hospital, or part of an IPPS-excluded unit of an IPPS hospital and the satellite is always co-located with an unrelated hospital.
There are also "provider-based entities," defined as a "provider of health care services, or an RHC… that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of a different [emphasis added] type from those of the main provider under the ownership and administrative and financial control of the main provider, in accordance with the provisions of this section. A provider-based entity comprises both the specific physical facility that serves as the site of services of a type for which payment could be claimed under the Medicare or Medicaid program, and the personnel and equipment needed to deliver the services at that facility. A provider-based entity may, by itself, be qualified to participate in Medicare as a provider under §489.2 of this chapter, and the Medicare conditions of participation do apply to a provider-based entity as an independent entity." Because provider-based entities have their own CCNs and Medicare health and safety standards, they are not subject to survey as part of the hospital.. A hospital with four inpatient campuses is a hospital consisting of one main provider and three remote locations.
For hospitals that have not been accredited in accordance with their CCN, will they be required to be surveyed in this manner before July 15, 2010?
Beginning July 15, 2010, when hospitals are due for a resurvey, they will be required to be surveyed in accordance with their CCN. Also, if after this date a hospital is required to have a survey, such as due to a change in ownership, new patient care site, or follow-up to a complaint, the hospital is surveyed in this manner. Prior to July 15, 2010, if a hospital wishes to be surveyed in accordance with their CCN regardless of when they are due, the Joint Commission will accommodate the hospital’s wishes .
If a hospital is not surveyed in accordance with its CCN by July 15, 2010, then how will it be accredited in accordance with its CCN by this date?
By July 15, 2010, Joint Commission staff will establish an accreditation record for each hospital’s CCN based on the hospitals’ most recent accreditation survey. Thus, each hospital CCN will have a separate Joint Commission accreditation record and decision, and therefore, will be in compliance with the CMS’ requirement to be accredited in accordance with their CCN.
For a hospital that is not surveyed in accordance with their CCN by July 15, 2010, what are the implications for the hospital after this date?
For all intracycle activities, the hospital must be prepared to meet all Joint Commission standards and requirements and the CoPs consistent with the manner in which it has chosen to participate in Medicare as of July 15, 2010. For example, this means that the hospital must submit its own application and PPR and report performance measurement independent of any other hospital, but including all provider-based remote locations, satellites and departments.
For hospitals that have been surveyed as a single organization, but participate in Medicare separately, how will they be surveyed in the future considering each hospital must be surveyed and accredited in accordance with their CCN?
These hospitals can be surveyed independently of each other at various times during the 18-39-month "window" or concurrently. If the hospitals wish to be surveyed concurrently, the unannounced survey will begin with an orientation to the system organization/structure. This will commence in the first hours of the surveys, and then the survey teams, all at the same time will be dispatched immediately to each of the hospitals being surveyed. All Joint Commission standards/requirements will be surveyed at each hospital independent of the other hospitals being surveyed, and each hospital will receive an accreditation decision independent of other hospitals being surveyed.
If a site, which is currently certified and accredited as part of another hospital, wishes to seek a separate hospital provider agreement and CCN, will the site continue to be considered accredited until the site receives its Joint Commission survey?
No. If a site has been participating in Medicare as part of a hospital but applies for a separate provider agreement and CCN, it is considered by CMS as an initial applicant and must undergo a separate Joint Commission survey and accreditation, after it has legally separated from its "parent" hospital, before CMS will issue it a provider agreement and CCN.
If a site, which is currently accredited as part of another organization, wishes to seek a separate provider agreement and CCN, will it continue to be able to bill CMS under the prior CCN?
According to the CMS, once an organization/site separates from the original hospital and is a hospital in its own right, it may no longer bill CMS under the CCN of the hospital it was once part of. Any patients in this new hospital are now patients of the new hospital, not the previous hospital. Once the newly created hospital is certified for participation in Medicare and is assigned its own CCN, it may bill for and be paid for eligible services provided on or after its assigned effective date. For specific questions about CMS billing requirements/practices, it is recommended that the organization contacts its Medicare Administrative Contractor or legacy Fiscal Intermediary, as applicable.
If a Joint Commission survey team surveys an affected hospital before July 15, 2010, what will be the expectations for the survey team?
The Joint Commission survey team should survey the hospital in the usual manner. If there are any questions, the survey team should contact the field director on-call, who will discuss the situation with Ms. Gail Weinberger, Director, Accreditation Policy and Administration.