In the absence of a drop-dead accreditation deadline, experts stress business benefits and due diligence when selecting an accreditation organization.

The October 31 accreditation deadline for the first round of competitive bidding came and went, and now the race is on for round two. Conversations with four accreditation organization representatives yielded a common theme: Don't rush for round two, and view the process as more than a ticket to reimbursement.

HME Today: How can accreditation organizations use the experiences of competitive bidding (round one) to instill a sense of urgency for round two?

Sandra C. Canally, RN, president, The Compliance Team Inc, Spring House, Pa: It is CMS that has to instill the sense of urgency with the release of the drop-dead date. Providers are not listening to the accreditors in terms of getting them to come forward.

Robert J. Floro, director, home care accreditation program, for The Joint Commission, Oakbrook Terrace, Ill: I really do not think it is an accreditor's role to create a sense of urgency. The industry is undergoing a culture change, and until DMEPOS suppliers embrace accreditation as a method to achieve quality improvement, risk reduction, and patient safety, all accreditors' pleadings will go unheard. As the culture evolves and change occurs, we will see DMEPOS providers embracing accreditation as more than just a means to reimbursement. I encourage all accreditors to aspire to this philosophy as well.

Many accreditation organizations promote quality within the entire organization and view the complete picture of a company, from leadership to policies to rights and ethics. I encourage all accreditation organizations to use this approach, because the future of our industry depends on it. If we want to be considered professionals, and be reimbursed for our services as well as the equipment, we must all raise the quality bar, including all accreditors.

Mary K. Nicholas

Mary K. Nicholas, MHA, executive director of the Healthcare Quality Association on Accreditation (HQAA), Waterloo, Iowa: The sense of urgency has always been there. After going through "round one," we've seen, felt, and heard the stress that suppliers have experienced in trying to prepare their bid and work toward accreditation. My advice all along has been to start and engage in the accreditation process while there are no external deadlines placed on the suppliers. And in doing so, the pressures will be lessened with the goal of more positive results.

Timothy L. Safley, MBA, RRT, RCP, HME clinical advisor for the Accreditation Commission for Health Care (ACHC), Raleigh, NC: Significant problems were brought to light with the competitive bidding process. The most common problem was that the bidding system was unnecessarily complicated. Additionally, there were issues with outdated bidding items that companies had to deal with. It seems that a lot of companies that started completing the bidding process [late in the game] took the accreditation phase of the competitive bidding process as a secondary activity. These companies decided not to take accreditation seriously, because they had so much research to do just to place their bid into the CBIC system.

Accreditation is not a hard process, but it does take time to understand the requirements of each accreditation company. When multiple areas that affect a company's day-to-day operations need to be reviewed to make sure that accreditation requirements are being met, things that normally would be an easy fix become time-consuming. Therefore, the processes are just not completed.

Companies that waited went into "panic mode," and simple processes of their business were left up to chance to be fixed. Some companies thought that the competitive bidding process would be obsolete, and in the last few weeks before the deadline, they tried to put things in place. Competitive bidding may or may not be modified for the second round; but the accreditation process is not going away, and waiting to prepare is just going to cause a unnecessary anxiety.

HME Today: How has the role of accreditation agencies changed and evolved over the last few years, and what do you think the future holds?

Sandra C. Canally

Canally: The role of the accreditors has evolved into the implementation arm for CMS, in terms of enforcing the Medicare Modernization Act requirements. In addition, there is an increased [demand] across the board for reports and more. Once CMS has various systems in place, it should go smoother.

Floro: The role of The Joint Commission has not changed since 1988. We have held and will continue to hold organizations accountable for quality services and patient safety. Our role as a means to reimbursement is temporary, and should not be construed as the primary reason for accreditation. With that said, we must address the reality that many DMEPOS organizations are driven to accreditation by the reimbursement factor, and realize the relative worth of accreditation only after they have been accredited for a period of time. It is the role of the accreditor to provide and support that relative value.

The future will provide a changing landscape for accreditation. Many accreditors with philosophies similar to The Joint Commission's will continue to support the mission of quality and safety as a core value, and not compromise their values for the sake of market share. Other accreditors will provide less rigorous scrutiny, as has already been demonstrated, thus rendering an accreditation product that is significantly different from the model embraced by The Joint Commission. For DMEPOS, the quality of the accreditor, as well as the future integrity of the accreditation product, lies partially with accreditors—yet very clearly with CMS. CMS has validated 10 accreditors for DMEPOS, some old and some new. CMS must now recognize the variability in the accreditation products approved through its recognition process, and uphold the quality of accreditation through the validation survey process.

Nicholas: From an accreditor's point of view, the role really hasn't changed. Standards of solid business practices are imposed and supported, and companies achieve an award based on accomplishing the infusion of the standards into the daily operational structure. From an industry point of view, AOs are now viewed as an extension of CMS. I believe that the future may hold an even deeper stronghold of information gathering and reporting, and that the AO's conduit of information will be critical to the future of the suppliers and for maintaining supplier numbers.

Safley: Accreditation is still in its early stages of development. The quality standards are minimal compared to what is required for home health agencies to be approved. We believe that over the next several years, more clarification will be listed in the quality standards for accreditation organizations to monitor. This has been enforced with the release of the new quality standards dated August 2007. There has been an expansion of the original standards from 14 pages to 18 pages. Although the changes appear to be minor, CMS is still adjusting its requirement to better explain what accredited organizations have to monitor for accreditation to be granted.

HME Today: Among HME providers who have not yet become accredited, what is the biggest misconception about the process?

Canally: There is a belief out there that all accrediting bodies are the same, and the experience of accreditation is filled only with horror stories. We have an all-inclusive program designed for small business providers that can be implemented in as little as 4 hours a week. With that, the pain is eased.

Robert J. Floro

Floro: The most significant issue here is the preparation for accreditation. Many DMEPOS organizations seeking accreditation at this point have not considered it in the past, and are now seeking accreditation to access a third-party payor. Accreditation is a cultural change for organizations, and many are not embracing it as such.

They are preparing for the "exam" (survey, if you will) rather than incorporating it into their corporate culture. As a result, many are not as prepared as they should be for the survey, and we are seeing the rates of adverse decisions for DMEPOS providers rise due to this fact. I encourage all organizations to assume a more serious approach to the philosophy of accreditation, and not just use it as a means to a payor.

Nicholas: I would have to say that we've seen more people (during the NCB process) who have the notion that accreditation is a "one-time action." In other words, suppliers who put together a policy and procedure manual think that they have now completed requirements. I have sensed that the rush to complete all requirements has overtaken the notion that integrating excellent business practices should be the ultimate priority.

Safley: The biggest misconception is that it is extremely hard to be granted accreditation. The majority of required items is comprised of work that a company does each day when it opens its doors. Most requirements are already being completed by a company, but there is no ongoing monitoring of these processes.

The ultimate goal of any DMEPOS company is to help the patients they serve. Despite the "bad apples" we hear so much about, the vast majority of people care about the products and services that are delivered to their patients. The processes that these companies follow have just not been implemented and put in writing. Policies are not that hard to write, but companies need to take the time to write down what they do and then actually follow what they have written.

HME Today: What should providers look for when selecting an accreditation agency and what should they avoid?

Canally: When choosing an accrediting body, you need to choose the right one for your operation. Ask what the total cost will be, and remember that it is not an apples to apples comparison. Some programs are not easily understood and suggest you buy a policy manual and hire a consultant. Determine what is included in the fees and what are the extras.

Floro: Accreditors must bring value to an organization. If a DMEPOS supplier pays a fee to become accredited, there should be value obtained for those fees in addition to access to a payor. The following are elements of value that are keys to a good accreditor

1. Experience is essential. Any accreditor can survey an organization against standards and "approve" them for Medicare reimbursement. The real value is in the ongoing relationship with the organization, and only experience can bring that value.
2. Consistency of accreditation decisions should be a crucial expectation. DMEPOS organizations must understand how accreditation decisions are made, and the consistent rules that apply. Organizations that are being accredited during this first round should have a reasonable expectation that the decisions rendered will be consistent over time, and not varied at the whim of the accreditor.
3. The accreditor should not mix consultation prior to the survey, with the end product being evaluated. Preparing an organization for an exam, then administering that exam, is a conflict of interest on the part of the accreditor—and is inconsistent with the philosophy that the accreditor is providing a third-party evaluation.
4. The credentials of the surveyors should be examined as an essential element of the quality of the accreditation decision. DMEPOS providers should understand the qualifications and training an accreditor provides for its surveyors so there is improved consistency in accreditation decisions.
5. Finally, is the survey process merely a review of records and policies, or does it bring actual value to the organization? Again, when an organization pays for accreditation, there should be a reasonable expectation that those fees bring value. Ultimately, accreditation is more than a route to access a payor. It is a cultural change within our industry that we should embrace as the norm.

Nicholas: Providers should seek a good match for their organization. They should seek a company that is responsive to their needs, and supportive of their endeavors. They should review cost, time requirements, efficiency, and how user-friendly the process will be for them.

Timothy L. Safley

Safley: Thoroughly research all aspects of what the accreditation process is about. ACHC wants to offer a process that would not only be educational, but also improve a company's business model as to how it looks at its overall business. This is why we are the only accreditation company that went outside our industry and sought ISO certification. There was not any specific agency that accredits the AO. We want to make sure that we have more to offer our partners in accreditation than just an exercise in paperwork. At the recent Medtrade meeting, I heard people say that we accrediting organizations all started to sound alike. This is why each provider needs to take the time to call other companies that have been granted accreditation by the AOs and ask how the overall process went. Ask how beneficial the process was in helping the company improve customer care and financial performance.

Call an AO and find out how long it takes to talk to somebody who can answer your questions. Ask how the AO is working with the industry to improve patient care. Review the standards and make sure you can understand them and what they mean for your company. Call the AO and ask for clarification of standards, and note the callback time in response to your questions. Call other companies that are accredited by the AO that you are researching and get more details. Make sure your AO is recognized by the insurance carriers of your primary payors. Remember, CMS is not the only payor that you deal with.