Is Your Ambulatory Surgery Center Licensed, Accredited or Certified?

Author: Davide W. Mercier, MD;Beverly K Philip, MD

As anesthesiologists, our primary responsibility is ensuring our patient’s safety as well as demonstrating this quality of care to both our patients and health care payers. Making certain that your surgery center meets or exceeds accepted standards of operation is one way you can help to ensure your patients a quality outpatient experience. But which standards are most likely to lead to an enhancement of safety? Should your facility strive for licensure, certification, accreditation, or some combination of the three? While these terms are often used interchangeably, they have very different meanings and implications.

Licensure is an authorization that allows the operational activities of a facility such as an ambulatory surgery center or hospital. Currently, licensure of ambulatory surgery centers is required by law in 43 states.

Certification is the procedure and action by which the Centers for Medicare & Medicaid Services (CMS) evaluates and recognizes an institution that has met all requirements or conditions for participation in the Medicare program. Certification is required of any center that wishes to bill Medicare or Medicaid for services rendered to patients.

Accreditation is a voluntary process undertaken by an institution to demonstrate that it meets or exceeds certain national criteria. For example, the following are the standards promulgated by the Accreditation Association for Ambulatory Health Care (AAAHC):

1. Patient Rights

2. Governance

3. Administration

4. Quality of Care Provided

5. Quality Management and Improvement

6. Clinical Records and Health Information

7. Professional Improvement

8. Facilities and Environment

9. Anesthesia Services

10. Surgical and Related Services.

Ambulatory surgery centers interested in demonstrating their commitment to quality can seek accreditation from an independent accrediting body. Currently, three major groups are largely responsible for the accreditation of ambulatory surgery facilities in the United States. These are the Joint Commission, AAAHC and the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). The process of accreditation involves a self assessment by the organization, followed by an on-site review by the accrediting body. While accreditation is voluntary, 25 states and the District of Columbia either recognize or require accreditation of certain types of ambulatory surgical organizations. For example, since 1996, California has mandated accreditation of all outpatient facilities that administer sedation or general anesthesia. Additionally, some states require accreditation of office-based surgery practices. Clearly, understanding the laws of your particular state and how they pertain to your type of facility is vital in navigating this evolving area.

Where to start? If required by your state, licensure must be obtained first in order to begin operations and to qualify for the accreditation process by any of the national accrediting bodies. Fortunately, in certain circumstances, more than 20 states will recognize accreditation by The Joint Commission, AAAHC and AAAASF in lieu of their own state licensure or other regulations. Therefore, contact with your appropriate state agency or one of the accrediting bodies, via a phone call or a Web site visit, may eliminate the need for undertaking both the accreditation and state license survey.

Centers that plan to care for Medicare or Medicaid patients must attain CMS certification via a state CMS survey agency. However, in November 2007, CMS noted in a memorandum to state survey agency directors that “CMS longstanding policy makes complaint investigations, recertifications, and other core work for existing Medicare providers a higher priority compared with certification of new Medicare providers.” Fortunately, the same memorandum stated that providers have the option of attaining an accreditation that conveys deemed status and that this would likely be the fastest means to Medicare certification. So, if you want your center to be Medicarecertified, the quickest route is through accreditation with the Joint Commission, AAAHC or AAAASF, with the election of the deemed status option.

What is this thing called “deemed status”? The Joint Commission, AAAHC and AAAASF have agreements whereby they provide CMS with evidence and verification that an institution it has accredited meets and/or exceeds the required federal regulations, including the “Conditions for Coverage.” Once verification is complete, CMS has agreed to deem the organization as meeting Medicare and Medicaid certification requirements. To achieve this, the facility must meet certain survey requirements specific to CMS and not otherwise required by the accrediting agency (e.g., the survey must have been unannounced). Thus, an organization accredited under deemed status by a national accrediting association is not required to undertake a separate survey by CMS. What are the CMS Conditions for Coverage? They comprise 10 sections that include:

1. Compliance with state licensure laws

2. Governing body and management

3. Surgical services

4. Evaluation of quality

5. Environment

6. Medical staff

7. Nursing services

8. Medical records

9. Pharmaceutical services

10. Laboratory and radiologic services.

The specific descriptions for each category of the CMS conditions for coverage can be found at access.gpo.gov, and of course are provided by the accrediting organizations when you notify them that you are electing to obtain deemed status with your accreditation.

If accreditation is voluntary, why seek it if your center is already licensed or certified? First, accreditation shows patients and payers that your facility has a continuing commitment to quality care and safety. By undergoing the self-assessment and educational process leading up to the survey, there is an inherent benefit that non-accredited facilities do not experience. Gaining and maintaining accreditation also allows you to benchmark your center’s performance against important industry standards. Finally, as noted throughout this article, many required mandates such as state licensure and desired qualifications (such as CMS certification) can be attained simultaneously with accreditation.

Obtaining and marketing your facility as being accredited show patients your commitment to quality care. As health care plans continue to ratchet down payments to providers and facilities, being an accredited facility may be helpful in negotiating improved payments. Thus, while the process can be challenging and time-consuming, there are many advantages to gaining and maintaining accreditation.

Helpful Contact Information:

www.aaaasf.org (888) 545-5222

www.aaahc.org (847) 853-6060

jointcommission.org (630) 792-5000

Bibliography:

• http://www.ascassociation.org/faqs/ascregulations/.

• http://www.aaahc.org/eweb/dynamicpage.aspx?site=aaahc_site& webcode=acc_pt_care.

• http://www.aaahc.org/eweb/dynamicpage.aspx?site=aaahc_site& webcode=state_laws.

• http://www.aaaasf.org/history.php.

• http://www.surgicenteronline.com/articles/gaining-maintainingaccreditation.html.

• http://www.cms.hhs.gov/surveycertificationgeninfo/downloads/scletter08-03.pdf.

•http://www.jointcommission.org/accreditationprograms/ambulatorycare/accreditation_process/ahc_deemed_status_faqs.htm#general1.

• http://www.access.gpo.gov/nara/cfr/waisidx_05/42cfr416_05.html.

October 2008