Facility Accreditation: Wait and See or Take Action Now?

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As the number of new O&P facility accreditation applications level off, O&P accreditation organizations respond with simpler, faster processes.

Wayne Rosen, CPO, CPed, FAAOP, owned and operated an O&P facility for more than 20 years, but when illness struck in 1998, he sold his business. In 2008, he decided to open a new O&P business, but the Florida resident found that the O&P landscape had changed; because his proposed site would supply diabetic footwear, the Centers for Medicare & Medicaid Services (CMS) required that the facility be accredited before it could open.


"This is not [a situation where] you get 80 percent and you pass," Rosen says, who admits the accreditation process was a bit nerve wracking. "This is all or nothing."

Rosen now owns two facilities, one in Pembroke Pines and another in Pompano Beach, Florida. Although the self-described "stickler for documentation" received his accreditation certificate with no issues to correct, he says the process helped him to set up his new business in a better way. His facilities' patient-documentation procedures are more comprehensive than they were back in the 1990s, he explains. Monthly staff meetings follow a strict format, including a review of safety issues, patient satisfaction surveys, billing errors, and claim denials.

"The meetings are more extensive…and that makes for a good meeting," he says.

He updated his facility in other ways as well, noting that each patient room now includes hand sanitizer, chairs with arms, and garbage cans with lids.

Rosen explains that these improvements came before the accreditation surveyor set foot in his door. He followed the pre-survey checklists the accrediting organization provided, and although he was nervous when the surveyor made the required unannounced visit, he was ready. Going through the accreditation process was "a positive experience," Rosen says. "It proved to me we were doing it the right way."

O&P Exemption Still in Place

On September 30, 2009, accreditation became mandatory for suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) in order to obtain and maintain a CMS supplier enrollment number. The mandate includes all O&P and pedorthic facilities that dispense diabetic footwear for beneficiaries with diabetes. O&P facilities that provide certain ancillary devices including canes, crutches, walkers, and oxygen-related items, such as nebulizers, also must be accredited. However, CMS still has not lifted its exemption for most O&P businesses.

Because many O&P patient care facilities do not provide such ancillary items, some have adopted a "wait and see" approach. As a result, the number of new O&P facility accreditations seems to be leveling off. When The O&P EDGE asked the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) and the Board of Certification/Accreditation, International (BOC) to comment on the topic, representatives from both organizations said that regardless of whether or not CMS requires accreditation for your facility, there are many reasons why O&P suppliers should consider it. To help facilitate the process, ABC and BOC are looking at ways to make the facility accreditation process easier.


Why the Downward Trend?

According to ABC, O&P accreditations spiked in 2008 and 2009, a time in which it was unclear whether CMS would make accreditation mandatory for all O&P providers. But since CMS has yet to announce when the statute exempting O&P facilities from mandatory accreditation will possibly be changed, applications have leveled off; over the last year, the number of new O&P accreditation applications has gone back to pre-2007 levels, says Catherine A. Carter, ABC's executive director.

BOC says that the number of its O&P facility accreditations has "flattened," meaning previously accredited facilities are renewing their accreditations, but few new O&P facilities are applying for first-time accreditation. BOC's Director of Facility Accreditation, Wendy Miller, doesn't believe the numbers will increase until CMS removes its accreditation exemption, especially with smaller "mom and pop"-type O&P facilities.


"If they don't have to do something, they are not going to do it," she says.

The lack of new accreditations may also reflect a priority shift by the accreditation organizations themselves. When CMS exempted most O&P facilities from mandatory accreditation, BOC says it focused its energies on DME facilities that were included in the 2009 mandate.

Accreditation Is Becoming Simpler, Faster

But there may be another contributing factor to the leveling out of O&P facility accreditations. Both BOC and ABC say O&P facility owners have told them that they are apprehensive about the accreditation process, and both organizations have responded by simplifying the process to make it easier and faster.

Recently, BOC rolled out an automated data collection system, whereby letters and certificates are automatically generated, and the surveyor, BOC staff, and facility owner communicate via e-mail instead of by U.S. mail or fax. Surveyor laptops capture signatures, and applications are completed online.

Upgrading the system shortened facility owner wait time and frustration, Miller says. Before the 2009 deadline, it could take six to eight months for a facility to receive an accreditation decision from BOC. Now the wait is less than 90 days and sometimes as short as 60, Miller says. The new system also resulted in improved communication to suppliers regarding where they stand in the accreditation process.


ABC has also found ways to streamline its accreditation process. Stephen Fletcher, CPO, ABC's director of clinical resources, says that ABC has simplified the language and reduced the redundancies in its accreditation standards. The new standards, which as of this writing were scheduled to be released in February, are clearly defined and no longer require a statement of intent to explain their scope, Fletcher explains. It's also easier for facilities that don't provide certain categories of Medicare-covered services, such as rental equipment, to understand which standards don't apply to them. In the past, standards were written more broadly to encompass all possible scenarios; now they are broken into subcategories, so if a facility is not providing those services, those specific standards would not apply to them.

"Our new standards ultimately make it easier for applicant facilities to know which aspects of their practice are critical to ABC and to Medicare and what will be examined during the survey process," Carter says.

BOC has reduced its application size from 20 pages to two. In August 2010, BOC unveiled a more user-friendly website, which includes step-by-step instructions for the facility accreditation process.

"We are trying to look at it through [the facility owner's] eyes and trying to make it as simple as possible," Miller says. "We…don't want this to be an extra burden."

Both ABC and BOC state that becoming accredited now will make the process that much easier when CMS requires accreditation for all O&P facilities, adding that accreditation is important for all O&P facilities, regardless of when CMS rescinds the exemption.

"The supplier sites that are non-compliant with supplier standards and/or are fraudulent will be eliminated," Carter says.

Many O&P facility owners may not realize that third-party payers such as CMS and Blue Cross/Blue Shield are beginning to enforce accreditation as a requirement to becoming a preferred provider, Miller adds. In addition to the mandate that facilities be accredited if they dispense diabetic shoes or inserts or provide certain ancillary devices, facilities that are not owned by a certified orthotist or prosthetist also must be accredited.

Facility accreditation is also important for consumers, the organizations say. Over the last 20 years, the O&P model of delivering healthcare has changed significantly. Today, healthcare is being delivered by many different types of professionals, as not all O&P care is delivered by certified practitioners in the traditional O&P clinical setting.

Improving Business Practices


Like Rosen, Dennis Janisse, CPed, president and CEO of Milwaukee, Wisconsin-based National Pedorthic Services (NPS), notes that facility accreditation has helped to improve his business practices. Janisse most recently completed the ABC facility accreditation process for his pedorthic facility in 2010.

In previous years, Janisse says he would simply fill out the required forms for the Board for Certification for Pedorthics, which was the pedorthic profession's only certification and accreditation organization at the time. This time, however, a surveyor from ABC made CMS-required unannounced visits to all seven of his facilities, examining patient records, employee credentials, and safety procedures, as well as checking NPS' compliance for the other standards.

"It was a whole different ball game," says Janisse, who admitted that initially he felt intimidated. "[The new accreditation process] is so much more intensive and so much more meaningful."

As a result of the facility accreditation process, he says that he and his staff now post a certificate of insurance at every location, and all of his employees at each satellite location have copies of company policies. Medicare standards are provided to every patient, and the staff keeps separate files for each patient's medical and billing records.

"It really ends up being a learning experience," Janisse says. "The goal is not to fail you. They want you to pass. They are there to help you to be a better facility.

"The physicians, the nurses, physical therapists, and all the other members of the foot care team are going to respect you more if you have gone that extra step toward being an accredited facility," he concludes.

Susan Glairon is a freelance writer who lives in Longmont, Colorado.

Top 10 Mistakes Facilities Make When Applying for Accreditation

  1. Misunderstanding the standards. Call your accrediting organization if you have a question.
  2. Incomplete patient files.
  3. Missing privileging information in personnel file for each non-credentialed staff member who comes in contact with patients.
  4. Credentialed practitioners do not sign off on notes from non-credentialed staff.
  5. Patient satisfaction surveys have not been conducted.
  6. The results of the patient satisfaction survey have not been evaluated.
  7. Lack of regular fire drills.
  8. Did not conduct and document a facility safety inspection in the past year.
  9. Policy and procedure manual has not been reviewed in the last year.
  10. Compliance documentation was not current.

Source: American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC).

Tips for a Smooth Accreditation Process

The Board of Accreditation/Certification, International (BOC) provided the following tips for making the facility accreditation process go as smoothly as possible:

  • Choose one of the ten organizations that have been awarded Deemed Status as an accrediting organization for DMEPOS.
  • Read the standards posted on the organization's website or on the CMS website. Remember that the accrediting organization you choose may require standards additional to Medicare standards in order to bring your business up to a high level of professionalism.
  • View the accreditation organization as a business that wants to help you. If you have questions about the process, call or e-mail the accrediting organization.
  • Do your best to become compliant with all standards before applying for accreditation.
  • Know the process. After an application, a supplier may receive a letter saying a site surveyor has been assigned and that the surveyor will show up at his or her facility unannounced. A few weeks after the survey, suppliers will receive the accreditation or a list of noncompliance issues. Once the supplier satisfactorily fixes any noncompliance issues and fills out a corrective action plan, accreditation will be granted.
  • Review your facility's Performance Improvement Policy (patient survey forms) as this is commonly an area where facilities are not up to par. Medicare requires all suppliers to have a Performance Improvement Policy, including call logs to track complaints from the time they arrive through the investigation of the complaint and its resolution. Upon accreditation renewal, previously accredited facilities must demonstrate the use of these logs.
  • Talk to your employees before submitting the application. Let them know where all required documentation is stored as surveyors also interview employees.
  • Be sure your business is open during the posted hours listed on your application so the surveyor does not arrive when your business is closed.
  • Once accredited, look for annual communication from the accrediting organization and send updates with any new information. These actions will streamline the process when it's time to renew.

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