The Blurred Line Between Medicare and Accreditation

We all know that you have to be accredited in order to have a Medicare billing number. Did you know that your accrediting organization and Medicare share data about your HME business? Are you aware of the difference between Medicare’s Quality Standards accreditors use and Medicare’s DMEPOS Supplier Standards, and what each of these means to your business?

When you enroll and re-validate your Medicare supplier billing number with the National Supplier Clearinghouse (NSC) using Form 855S or the Provider Enrollment, Chain, and Ownership System (PECOS), you inform Medicare about the products and supplies provided by each location of your business, the hours that the business is staffed and open to the public, and your accreditation organization.

The Difference In Standards

A Medicare representative reviews for compliance with the Medicare DMEPOS Supplier Standards, and an accreditation surveyor reviews for compliance with agency standards that integrate Medicare’s Quality Standards. In each case the Center for Medicare Services (CMS) is interested in identifying fraudulent behavior.

Think of Medicare’s Quality Standards as the framework for all accreditor standards. Regardless of whether you are accredited by The Joint Commission, CHAP, ACHC, The Compliance Team, HQAA, BOC, ABC, CARF, NABP, or NBAOS, Medicare’s Quality Standards are universally embedded within each accreditor’s requirements.

Accreditor Responsibilities

In order to be approved by Medicare to accredit Durable Medical Equipment Prosthetic Orthotic Supplies (DMEPOS) businesses, Medicare requires accreditation organizations to:

• Perform unannounced inspections for compliance with the Medicare Quality Standards
   
• Provide reports to CMS with any survey-related information
   
• Allow validation reviews by a CMS survey team to examine the results of the accreditation organization’s own survey procedure onsite
   
• Report all accreditation decisions, including suppliers denied accreditation
   
• Report all complaints related to the supplier
   
• Notify CMS of any changes in standards, requirements or survey process at the accreditor
   
• Permit its surveyors to serve as witnesses if CMS takes an adverse action based on accreditation findings
   

Each week, your accreditor communicates their database about all accredited organizations, including products each is accredited to provide. If you add a new product line, be sure to notify your accreditor and update your list of products. Your claim will deny if CMS is billed for a product you aren’t formally accredited to provide.

Accreditation organizations are also required by Medicare to ask probing questions about billing and financial viability of the company as a result of closings and bankruptcies that leave patients abandoned.

Your Accreditor and Medicare’s Quality Standards

CMS mandates that all surveys be unannounced. When your accreditation surveyor is on site, they are required by Medicare to verify the following standards. There are a few standards here that may catch you off guard.

Business Services

• Possess and publicly display all licenses, certifications and permits necessary for your business in an area accessible to customers. Make sure all licenses are up to date.
   
• Provide customers with written product information, including warranties and instructions for use.
   
• Have written procedures to prevent fraud, waste and abuse
   
• Have a designated a corporate compliance officer
   
• Can link equipment to beneficiary—that is, make, model and serial number on the delivery ticket
   

Financial Management

• Have accurate accounting and billing practices and can track actual revenues and expenses
   
• Have an operating budget with projected revenue and expenses for coming year
   

Human Resource Management

• Job descriptions include staff qualifications, training, experience and continuing education requirements
   
• Document competencies for staff who deliver, set up items and train patients
   
• Proof of clinical licensure or certification and its legitimacy
   

Consumer Services

• Instruct patients on use, maintenance and potential hazards of item
   
• Provide information about expected time frames for receipt of delivered items
   
• Verify receipt by patient with signed and dated delivery ticket
   
• Provide contact information, hours of service, after-hour access and emergency coverage.
   
• If you provide any sort of respiratory services, such as oxygen, mechanical ventilators, CPAP, respiratory assist devices, IPPB, and nebulizers, you must have a way for patients to contact you after hours.
   
• Provide options to rent/purchase
   
• Provide warranty information
   

Complaint Process

• Notify MD within five calendar days if prescribed item cannot be provided
   
• Notify patient within five calendar days of receiving their complaint to confirm your receipt of the complaint
   
• Within 14 days, notify beneficiary in writing of results of investigation and response. If your staff documents a complaint, a letter must be written within 2 weeks.
   
• This standard requires tracking of timeliness of written response to complaints in the Performance Management process.
   
• Maintain copies of complaints, investigations and responses to beneficiaries
   

Performance Management

Measure and document in a report:

• Customer satisfaction
   
• Timeliness of responses to questions, problems, concerns (Did you respond to complaint in writing within 14 calendar days?)
   
• Impact of supplier’s business on patients’ access to items, services, info (Did customers get what they needed?)
   
• Frequency of billing and coding errors (Were claims unexpectedly denied?)
   
• Adverse events due to inadequate or malfunctioning equipment, items or service
   

Product Safety

• Identify, monitor, and report (safe medical device, FDA, etc.) item failure, repair, and preventive maintenance
   
• Investigate injuries or incidents within 24 hours (patient hospitalization or death)
   
• Have an emergency plan—coordinate with other providers if necessary
   

Information Management

• Patient records are accurate, pertinent, accessible, confidential
   
• Documented patient training
   
• Instruction includes: Features, routine use, troubleshooting, cleaning, maintenance, safety considerations, warranty, infection control issues
   
• Verify the beneficiary received training and instructions on the use of items
   
• Record in the beneficiary’s record such instruction was provided
   
• Provide follow-up as appropriate
   

Complex Wheelchairs, Rehab

• Employ at least one ATP per business location
   
• Trained technician supporting the ATP
   
• Annually complete at least 10 hours of continuing education per year specific to rehab technology
   
• Able to program and repair electronics associated with power WC, alternative drive controls, power seating systems
   
• If patients are evaluated at supplier’s facility:
   
  • Private, clean, safe rooms for fittings and evals
     
  • Repair shop located in or in close proximity to facility
     
  • Area appropriate for assembly and modifications

The Medicare (NSC) Site Visit

The NSC is also aggressively conducting unannounced on-site inspections as part of the routine re-enrollment process. This inspection occurs with NSC enrollment and re-enrollment (approximately every three years).

When a Medicare representative performs an inspection, he/she is working the list of Medicare DMEPOS Supplier Standards. To obtain and retain your billing number, a DMEPOS business must demonstrate compliance with these standards.

Create a binder where you keep all of the necessary documents that demonstrate compliance. Download a copy of the Medicare Binder List here. This binder should be available at each location that has a billing number, in a set spot such as on top of a particular file cabinet. All appropriate personnel in each location should be trained to give this binder to the inspector when he or she arrives. At the same time, the staffer should call a designated management person to coordinate the visit. (The telephone number and name of this person should be prominently listed on the first page of the binder.) It’s wise to have two people trained to manage these unannounced visits, should one occur during a vacation period.

If you train your staff on the binder and its contents at least twice a year, people will know and get comfortable with the process, the local Medicare contractor will get in and out in a short period of time. My mottos are, “Get them in and out as fast as possible,” and, “Be careful what you say.”

Instead of giving patients the full page of 30 DMEPOS supplier standards, you are allowed to distribute this instead:

“The products and/or services provided to you by (your company name) are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g. honoring warranties and hours of operation). The full text of these standards can be obtained at http://ecfr.gpoaccess.gov. Upon request we will furnish you a written copy of the standards.”

To be successful, a supplier must understand the enforcement landscape and be proactive. Being reactionary and responding to an action when it hits your doorstep is not enough. Understanding the background and where hazards are coming from helps you to be prepared for both the accreditor and Medicare site visit. Download the printable binder PDF at homecaremag.com/DMEPOS-binder.