Time’s Up!

Unless you’ve been living under a rock for the past few years, you are no doubt aware that the Medicare Modernization Act of 2003 requires that medical equipment providers who bill Medicare for identified Part B products and supplies will have to become accredited. Accreditation programs for DME have been around for more than a decade, but your company’s first attempt at accreditation may prove no small task.

Background

When the industry learned that accreditation would be mandatory, we also learned that accreditation organizations would be the bodies assigned to enforce and manage compliance. CMS is not contracting with state health departments to ensure compliance with this group of standards, as is their practice in home health and hospice.

In September 2005, CMS released 104 pages of draft quality standards with an over-the-top addition of many extreme, and sometimes ridiculous, expectations. It looked as though the contractor CMS used gathered everything every home care provider might be required to do to comply with any regulatory or accreditation requirements, and then turned these tasks into CMS’ quality standards. At the time, there was an outcry from the industry, and a sea of comments were submitted.

So in August 2006 — after 5,600 comments had been received on the draft standards — CMS released its final quality standards. These standards, which ended up at only 14 pages, are straightforward and very much reduced from the requirements that had been included in the draft proposal.

Next, all accrediting organizations that wished to be recognized by CMS sent their programs in for review. Some of the programs had existing standards that were more stringent or comprehensive than others. But it subsequently became clear that, ultimately, CMS didn’t care what other standards the accreditors required in their programs as long as they had standards that met the government’s final quality standards word-for-word.

CMS also required that the accreditors award accreditation to providers who meet the agency’s quality standards, regardless of whether or not they pass any additional standards the accreditor may have in place. It will be interesting to see how this is going to work in the upcoming months.

Previously, accreditation for DME has been voluntary, and providers have chosen the accrediting organization they wished to use. Until this year, only some networks and managed care organizations have required accreditation in different areas of the country.

Also, surveys had always been scheduled with providers, but CMS now requires that all surveys, even those for a corporate office, must be unannounced. This is an easy process for an accrediting organization but a challenge for corporate and network surveys, where administrative staff may need to be present for a survey even though they may not reside where the corporate office is located.

Among other requirements CMS has imposed on its 10 approved accrediting bodies, the agency also requires that these organizations:

• Prioritize surveys for those suppliers in the MSAs selected for competitive bidding in 2007;
• Prioritize surveys for those suppliers who need to bid in the second round; and
• Consider any previous accreditation, certification and/or licensure findings that indicate that DMEPOS quality standards are being met at the time the accreditation organization surveys the supplier.

The Link with Competitive Bidding

At this time, there is no final date for when all providers must be accredited, but for now, it is required that providers who wish to participate in competitive bidding must be accredited.

Competitive bidding is scheduled to begin this year in 10 of the country’s largest metropolitan statistical areas — excluding New York, Los Angeles and Chicago.

If you are in any of the potential MSAs that CMS has targeted, your time has come. And when an additional 70 MSAs are brought on for bidding in 2009, it’s going to be crowded. The lesson is that there’s no time or good reason to wait any longer. The question is, however, how do you decide which accrediting organization is right for you?

Selecting Your Accreditor

The truth is, with most of CMS’ “deemed” accreditors, your accreditation generally lasts for three years. If you are unhappy with your accreditor, then you can switch to another before your next renewal.

There are a few items you should consider, however, when making your selection.

• CMS is not your only payer Don’t select an accreditor until you’ve done your homework! You may already be working with networks or third-party payers that require accreditation. While CMS has identified 10 accreditors, your networks and payers may recognize only two or three of them. Before making your final choice, check with your payers and networks first to see if you are limited to certain accreditors. We would expect that of the accrediting organizations identified by CMS that are able to meet the ongoing requirements, more payers that have recognized only a few accreditors will recognize additional accreditors as well.
• The fee should not be the main reason for your selection Many providers make a selection based on fees, looking for the least expensive. This can best be described as penny-wise and pound-foolish. As you review, you will find that many of the accreditors charge fees that are within a few hundred dollars of each other. Most of these organizations are non-profit, and while some may have programs for accreditation of other services, those services do not necessarily subsidize the cost of DME accreditation. All pay fees to their surveyors, which average about $1,000 for the first day. Additionally, the organizations have administrative costs to cover. This is not about cheap, this is about the relevance of the program to your line of business and your ability to meet the requirements without having to hire staff just to maintain your accreditation.
• Ongoing requirements and renewal While the accrediors have many similarities, there are several with specific requirements you need to be aware of.
  • Is the accreditation for one, two or three years?
  • What, if anything, are the requirements for in-between years?
  • How much ongoing time and staff effort is required? If you have to hire a $40,000-a-year staff member just to maintain your accreditation requirements, you have selected the wrong program. However, if you are short-staffed and have to hire staff to maintain a full-service, quality program, then you should not consider these as costs associated with the accreditation program.

• A paper or electronic process Some of the organizations are more “tech savvy” than others. Many require a paper process for providers to submit their information, while others are very high-tech. If you don’t know (or want to know) how to turn on a computer, an electronic program is not for you. This is not the time to learn.
• Interviews/perceptions of programs Narrow your search to two to three organizations, and then start a dialog with them. Note that if you can’t reach an organization while you’re looking, you’ll most likely not be able to get help when you need it to get your questions answered.

Your Peer’s Experience

Talk to your peers. Ask if they were satisfied with the accreditor they chose, the process, the surveyors who came and the outcome.

I’ve never met anyone who thought their accreditation was a waste of time. All feel that it brought value to their business and was a worthwhile endeavor. But I’ve met MANY providers who were unhappy with their accreditor and changed to another at their renewal.

You should also ask your accrediting organization for references of similar providers who can explain how their experience was with the organization. Every accrediting organization (that has not been recently formed) can provide you with a list.

Shop Around

Unfortunately, when CMS gave us the 10 deemed status accreditors, they did not give us a standardized list of products and services by which we can compare them to each other.

The listing that follows has been prepared in an effort to help you see which accreditor is an option for your company based on the products and services you provide. All have approval to accredit both local and national providers as well as those providing supplies via mail order.

In addition to information provided on the accreditors’ Web sites for this article, each of the 10 organizations was asked to provide the following information:

• Inception
• Length of accreditation term
• How fees are calculated
• Expected length of time for the program from application to completion
• If the program is new, how it has been tested. If the program is not new, what (if any) substantive changes were made in order to achieve CMS approval.

Not every accreditor responded to this request. These organizations may not quote the price you will be charged for accreditation if it is based on variables such as size, number of sites, volume of sales/rental, etc.

Contact the accreditors you are considering for an exact quote of the fees charged (for all that apply) including application, purchase of their standards manual, annual fees, renewal fees, surveyor expenses and any other fees involved. And, be sure to stay on top of this information as CMS may change requirements or add additional products to their list at any time.

With more than 25 years’ experience in management throughout the health care continuum, Mary Ellen Conway is the president of Capital Healthcare Group, LLC, Bethesda, Md., where she specializes in operations and regulatory issues in home health, hospice, medical equipment and accreditation. She can be contacted by phone at 301/896-0193 or through www.capitalhealthcaregroup.com.

Deemed Accreditation Organizations
(listed alphabetically)

Accreditation Commission for Health Care, Inc. (ACHC)
www.achc.org

Products: Full DME, Respiratory, Rehabilitation, Custom Orthotics and Prosthetics

Established: Nationally in 1996

Accreditation term: Three years

Fees: Base is $3,800 complete per site per survey day. Numerous association discounts in place that can lower the cost to $3,500

Time to complete program: From two months as long as appropriate policies and procedures are in place

Program changes: Adapted all CMS standards to further simplify the overall process

American Board for Certification in Orthotics and Prosthetics (ABC of O&P)
www.abcop.org

Products: Seven, including: 1) Comprehensive Orthotic and Prosthetic Accreditation; 2) Prefabricated Orthotics; 3) Off the Shelf Orthotics; 4) Post-Mastectomy; 5) Comprehensive Pedorthic; 6) Non-Custom Therapeutic Shoe; 7) Ancillary Assist Device, includes non-powered mobility devices but is only available as addition to organizations completing products 1, 2 or 5

Established: First accredited facilities in 1948

Accreditation term: Three years

Fees: Example, Post Mastectomy Provider: $325 application fee; $500 survey fee; $600 annual fee for each of three years (may be prorated in year one as year runs from December-November)

Time to complete program: From two to six months

Program changes: Redefined categories and types to be clearer and to match CMS product categories

The Board for Certification in Pedorthics (BCP)

This organization has merged with the American Board for Certification in Orthotics and Prosthetics. The facility accreditation process and application are being redesigned to assure compliance with the Deemed Provider requirements. See ABC of O&P.

Board of Orthotist/Prosthetist Certification (BOC)
www.bocusa.org

Products: Five, including: 1) Supplier providing a full range of orthotics and/or prosthetic services; 2) Supplier limited to fitting prefabricated orthotics devices, prefabricated therapeutic shoes, arch supports, prefabricated post mastectomy prostheses supplies; 3) A supplier that provides prefabricated HME/DME products and services; 4) A supplier limited to fitting prefabricated post mastectomy products and related supplies; 5) A supplier limited to custom and prefabricated shoes, arch supports and orthotics devices allowed within the scope of a licensed and/or certified pedorthic practice.

Established: 1984

Accreditation term: Three years

Fees: $1,475 due with completed application (for four or less locations) as application and accreditation fee; $750 survey fee; additional $750 survey fee for more than two locations or locations greater than 50 miles from original facility; annual renewal fee $575 for first four locations, $375 for each additional location.

Time to complete program: Not clear yet with integration of CMS quality standards

Program changes: Unannounced on-site surveys were added to program

Commission on Accreditation of Rehabilitation Facilities (CARF)
www.carf.org

Products: DMEPOS covered by CMS Rehabilitation and Customized Orthotics and Prosthetics Sections as well as specific items such as wheelchairs, prosthetic devices, therapeutic shoes

Established: Accepting applications after the final rule on competitive bidding for DMEPOS is released

Accreditation term: Three years, but one year or provisional accreditation may be awarded in some cases

Fees: $2,950 per location, which includes a standards manual, off-site review of the self-evaluation form and other materials, the on-site verification (including surveyor travel and accommodations), the accreditation decision, and survey findings. DMEPOS accreditation may not be blended with other CARF programs.

Community Health Accreditation Program (CHAP)
www.chapinc.org

Products: Full DME, Respiratory, Rehabilitation, Custom Orthotics and Prosthetics

Established: 1965

Accreditation term: Three years

Fees: Depends on size and scope of service. Generally starts at $4,600, includes one site visit day and includes standards; paid in four interest-free periods over the three-year cycle

Time to complete program: CHAP provides organizations with a self-study that the provider completes and then submits for review. Length of time to complete the written materials varies by organization, but averages at least two months. Once the completed self-study is approved by CHAP, surveys are scheduled within 60 days.

Program changes: No changes

The Compliance Team, Inc.
www.exemplaryprovider.com

Products: Include Solo Practitioners (PT, OT, Podiatrist), Boutique Pharmacies, Mail Order, Full Service Pharmacies, Full DME, Respiratory, Rehabilitation, Custom Orthotics and Prosthetics

Eestablished: 1998

Accreditation term: Initial sign-up period is for two years plus orientation. At the end of the initial sign-up period, the program renews on an annual basis.

Fees: Based on the types of products and services offered and on the number of stand-alone locations a provider has that can be reviewed in a single day

Range starts from $3,500 (for solo practitioners, e.g., podiatrist) to $6,900 (full service DME, pharmacy). Travel expenses additional with all fees, initial and renewal. After two years, annual renewal fees range from $1,495 to $1,995 plus travel

Time to complete program: Three months or less, although most take at least four months

Program changes: Minor revisions

Healthcare Quality Association on Accreditation (HQAA)
www.hqaa.org

Products: Full Service DME, Respiratory, Rehabilitation, Retail Pharmacies with DME, Retail Pharmacies with Limited DME and Custom Orthotics. Providers complete administrative standards and then select the products and services they provide such as Clinical Respiratory, Rehabilitation, Delivery, Retail Services and Mail Order.

Established: 2004

Accreditation term: Three years

Fees: Based on number of sites, size of organization. Can be immediately provided for individual organization on the HQAA website at www.hqaa.org/pricing_structure.asp.

Time to complete program: Generally three months. Process is completely paperless as a Web-based system that is available 24/7.

Program changes: Program was reviewed and some standards were consolidated, thus making it more streamlined.

The Joint Commission (formerly JCAHO)
www.jointcommission.org

Products: Full DME, Respiratory, Rehabilitation, Custom Orthotics and Prosthetics

Established: Hospitals in 1951, Home Care in 1988

Accreditation term: Three years

Fees: Spread over three years, starts at $3,500 for small, single-site providers.

Time to complete program: Six months

Program changes: CMS standards matched in intent, so no standards have been added

National Association of Boards of Pharmacy (NABP)
www.nabp.net

Products: Diabetic Equipment and Supplies, Enteral and Parenteral Nutrients, Therapeutic Shoes, Mobility Aids (crutches, walkers, canes, commodes), Wound and Ostomy Supplies, Urological Supplies, Off the Shelf Medical Supplies, Nebulizers, CPAP and Supplies

Established: First organizations will be surveyed in 2007

Accreditation term: Three years

Fees: Example, Single-site pharmacy ($2,145); application fee (Year One) $375; annual fees $150/year; one-day survey $1,500

Time to complete program: Once completed information is received at NABP, goal is to complete the process within 30 to 45 days

National Board of Accreditation for Orthotic Suppliers
www.nbaos.org

Products: Accredits facilities that supply custom-fabricated/made orthoses, custom-fitted orthoses, and prefabricated orthoses to Medicare beneficiaries. Accreditation available to facilities in which occupational therapists and physical therapists provide orthoses.

Established: September 2006. Program created by The American Society of Hand Therapists (ASHT) and the Hand Therapy Certification Commission (HTCC).

Time to complete program: Program is new and there is no information on test sites or trials. Explanation of process is as follows: Once initial application is completed and submitted with the fee, organization performs a self-assessment and a test survey. When organization feels that it has satisfactorily completed all requirements, documents are returned and application is processed. The surveyor plans on-site survey within 45 days of receipt.

Comparing Apples to Apples

Accreditation Commission for Health Care, Inc. (ACHC)

DME Group 1
DME Group 2
Medical Supplies
Respiratory
Rehabilitation
Custom Orthotics and Prosthetics

American Board for Certification in Orthotics and Prosthetics (ABC of O&P)

DME Group 1 (as long as Custom Orthotics and Prosthetics program is being completed)
Custom Orthotics and Prosthetics

Board of Orthotist/Prosthetist Certification (BOC)

DME Group 1
DME Group 2
Medical Supplies
Respiratory
Custom Orthotics and Prosthetics

Commission on Accreditation of Rehabilitation Facilities (CARF)

Rehabilitation- Manual and Power Wheelchairs
Custom Orthotics and Prosthetics

Community Health Accreditation Program (CHAP)

DME Group 1
DME Group 2
Medical Supplies
Respiratory
Rehabilitation
Custom Orthotics and Prosthetics

The Compliance Team, Inc.

DME Group 1
DME Group 2
Medical Supplies
Respiratory
Rehabilitation
Custom Orthotics and Prosthetics

Healthcare Quality Association on Accreditation (HQAA)

DME Group 1
DME Group 2
Medical Supplies
Respiratory
Rehabilitation
Custom Orthotics

The Joint Commission (formerly JCAHO)

DME Group 1
DME Group 2
Medical Supplies
Respiratory
Rehabilitation
Custom Orthotics and Prosthetics

National Association of Boards of Pharmacy (NABP)

DME Group 1
Medical Supplies
Rehabilitation (POV’s only)
Orthotics (Therapeutic Shoes Only)

National Board of Accreditation for Orthotic Suppliers

Custom Orthotics and Prosthetics

Definitions of Groups

DME Group 1 – Mobility Aids: Manual Wheelchair, Cane, Walker, Crutches, Stationary Commode Chairs, Wound Care and Ostomy Supplies

Urological Supplies: Bedpans, Urinals

Client residence visits performed on survey? Yes, if items are rentals. If not on rental, No

DME Group 2 – Manual and Electric Beds, Traction Equipment

Client residence visits performed on survey? Yes

Medical Supplies – Diabetic Supplies, Enteral Products (Non-home visit items)

Client residence visits performed on survey? No. Client interactions observed and paperwork reviewed.

Respiratory – Home medical equipment and supplies covered in this group include Respiratory equipment and supplies, Oxygen, Oxygen concentrators, reservoirs, conserving devices, high-pressure cylinders, oxygen accessories and supplies, home invasive mechanical ventilators, respiratory assist devices, continuous and intermittent positive pressure breathing devices, nebulizers

Client residence visits performed on survey? Yes

Rehabilitation – Items covered in this group apply to Manual Wheelchairs, Power Mobility Devices (PMDs), including Complex Rehab and Assistive Technology. PMDs include power wheelchairs and power operated vehicles (POVs) and accessories. Manual Wheelchairs include standard recliners, heavy-duty wheelchairs, standard lightweight wheelchairs, and hemi wheelchairs, armrests, leg rests/footplates, anti-tipping devices, and other Medicare-approved accessories.

Client residence visits performed on survey? Yes, if items are custom and if items are on rental

Orthotics and Prosthetics – Items included in this group include custom fabricated, custom fitted, custom-made orthotics, prosthetic devices, somatic, ocular and facial prosthetics, and therapeutic shoes and inserts, leg, arm, back, and neck braces, artificial legs, arms, and eyes, and extra-depth shoes with inserts or custom-molded soles with inserts (therapeutic shoes).

Client residence visits performed on survey? Yes, but depending on items provided (e.g. therapeutic shoes only), may observe patient interaction and/or record review alone.