If you failed to make the May 14, 2008, accreditation application deadline for round two of competitive bidding, there is still time. CMS extended the deadline to July 21, 2008, while the deadline for final accreditation went from October 31, 2008, to January 14, 2009. With mere days to go before July 21, we asked three accreditors to share their thoughts on MSAs, urgency, backlogs, and the true value of accreditation.

Greg Thompson, editor of HME Today: Beyond merely qualifying for Medicare, why is accreditation a good idea for HME providers?

Robert Floro

Robert Floro, director of the Home Care Accreditation program for The Joint Commission, Oakbrook Terrace, Ill, responds: The Joint Commission has been accrediting since 1988, and there was no Medicare driver at that time. Yet, we have continued to accredit organizations throughout that time. Our two main goals, through accreditation, are to maintain the quality of the services that are provided, and to improve patient safety. Certainly, if an organization can partner with an accreditor, the outcomes will be improved quality and improved safety. I think the remainder of those benefits are the by-products of those two main factors.

Also, [accredited] organizations have greater access to third-party payors, whether they be HMOs or other third-party payors, and certainly referral sources that refer DME services for organizations look at accreditation as a quality piece as well. There's got to be a certain amount of pull-through, relative to other third-party payors right now. We're already seeing that. CMS mandates accreditation. Many HMOs mandate accreditation. We're also starting to see some state Medicaids beginning to think about it, and other third-party payors, as well.

So, I think that the personality of the industry is moving toward accreditation as a standard within the industry. Many organizations use accreditation as a business platform. They take the standards and they take the documentation requirements, and they form their businesses and business plans around accreditation, and they find it a very useful tool. Risk reduction on the part of the organization, and on the part of the individual working for the organization, is certainly an outstanding value, as well. If the patients are safer, then the organization will not be as exposed from a legal standpoint, and relative risks will be reduced.

Beth Kolbe, MSPT, a licensed clinician and resource specialist for the Commission on Accreditation of Rehabilitation Facilities (CARF), Tucson, Ariz, responds: CMS is quite clear. They are not exempting anyone who has a Medicare Part B billing number who is providing any of the product categories that must be accredited, which are all listed on the CMS Web site. Regardless of whether the supplier is a physician, strip mall DME/HME supplier, podiatrist, gastroenterologist, physical therapist, or occupational therapist, anybody who bills DME—which includes prosthetics or orthotics shops—must be accredited.

CMS has announced its drop-dead deadline of September 30, 2009, and people have already waited since November 2006, thinking, "Oh, I don't think this applies to me. Maybe they'll exempt us," and thinking of all kinds of reasons. But now they're realizing that CMS really means this, and they haven't done it.

So, regardless of whether you're in the MSA and one of the 70 listed for round two, you must get accreditation. The reason it's important to start now is because there are only 10 accrediting organizations, and there are more than 100,000 suppliers, according to the National Supplier Clearinghouse (NSC). Many of those are not even thinking of it yet, or are just starting to think of it now. That's going to put a huge demand on these 10 accrediting organizations, of which CARF is one. They may not be able to meet the demand, and you can't necessarily blame us for that. This was announced in 2006. All who had to do it were advised or should have availed themselves of the information, and they're going to have to do it. So, regardless of whether you're in the MSA, I would start now to avoid that surge, which we know is going to come down the line in early 2009.

Mary K. Nicholas, executive director of the Healthcare Quality Association on Accreditation (HQAA), Waterloo, Iowa, responds: I believe that the providers that take accreditation seriously will see long-term positive effects in their overall organization. Implementing a quality improvement plan, where one really wasn't in place before, can absolutely produce long-term effects that benefit not only the organization, but also the customers who are served within an organization. There have been studies of businesses of all kinds showing that implementing quality improvement practices improves the overall effectiveness and efficiency of the organization. So beyond the accreditation award, it's the long-term effects that people should take into account and want to invest in, to improve their overall organization.

Beyond Medicare, there's a reason that so many managed care organizations are requiring accreditation. Third-party billing companies are requiring an accreditation award. People want to know, and payors want to know, that companies have put forth the effort to ensure positive business practices are occurring within each organization.

It's no different than the car manufacturing companies. The car manufacturers are certified by a global verification organization that ensures quality. They want to know that each of their suppliers is also certified. It's a chain of quality that the American consumer is becoming more and more aware of—and demanding. These are compelling reasons to look at accreditation beyond the immediate mandate that's out there.

Thompson: Among most providers, what do you think is the biggest misconception about accreditation?

Mary K. Nicholas

Nicholas: There are so many publications talking about the efforts to discontinue competitive bidding. There are a lot of folks thinking that's going to happen. Last year at this time, providers were under that assumption, and guessing that competitive bidding was going to go away. It didn't go away last year, [but the anti-bidding campaign], of course, doubled in its strength in the media, and in effort from all kinds of associations and companies wanting to talk to legislators, and wanting to discontinue moving forward on competitive bidding. So, folks are sitting back and waiting, and they think it's okay to wait. My response always is the old adage, It's not over until the fat lady sings, and we haven't heard any singing yet, so the plan—at least from an HQAA point of view—is to move forward with the guidelines that we have in place today. If things change, they change. But to sit back and wait and see if competitive bidding gets canceled is dangerous.

Thompson: At press time, CMS had not released the actual zip codes for the 70 MSAs involved in round two of competitive bidding. Do you think this may lead to providers being unexpectedly caught up in round two?

Floro: If you are not providing services within, for instance, a US Census Bureau-defined MSA, but CMS decides to expand beyond that Census Bureau MSA, there will still be a requirement to be accredited by September 2009. So the July 21, 2008, and the January 14, 2009, deadlines certainly are for those participating in round two competitive bidding, but organizations must begin to realize that accreditation is mandatory, regardless of whether they participate in competitive bidding or not.

Other factors that are involved in an organization's decision to participate in round two are certainly the opportunity for grandfathering and for subcontracting, and many organizations have already told us that they are simply not going to continue to do business with Medicare because their volumes just aren't high enough to cost-justify accreditation, or accreditation is outside the scope of their business in general.

If you think about the organizations today that apply to become accredited by the September 30, 2009, deadline, they have a very, very short window to submit their application, prepare for accreditation, be surveyed, and then—if there are any postsurvey activities—to complete those activities in anticipation of the January 14, 2009, deadline. So organizations are in a very tight timeframe. The September 30, 2009, date gives organizations at least enough time to contemplate accreditation, make a decision about what they believe is the best fit as an accreditor, and then begin the process. But organizations need to think about that today.

AAHomecare has talked about this. Many state organizations that I've visited have spoken to organizations and advised them to begin the process today, regardless of whether they're going to participate in round two competitive bidding.

Beth Kolbe

Kolbe: Those 70 MSAs were announced in January. Zip codes were not announced, we know that, but if somebody was just waiting for them to announce the zip codes, I don't think that's a good business decision. Sometimes we may be a bit brutal and will give answers to questions that the supplier may not want to hear. For instance, if they're calling me today and they have to have that application in by July 21, I won't tell them they can't do it, but I will tell them what they will have to do, and when they realize that, they're going to see that they may be missing out on this.

Nicholas: I think that potential exists. Absolutely. We get phone calls every day asking, "Are we going to be included?" Is this zip code included? And our response is always that we don't have the information at this point to be able to assist you in that decision. We always encourage folks to sign up because they don't want to be caught behind the deadline.

We are accountable to CMS in terms of their asking if we will have the capacity to serve all those that are going to compete in round two, and it's difficult for us to answer because we don't know the total extent of the MSAs at this point in time. I believe it's the NSC that's responsible for putting out the zip codes, and I think that it's unfortunate that the deadlines were announced and the zip codes were not. If in doubt, move forward. I think that's the best advice at this point.

Thompson: How long does it take to get accredited?

Floro: There are many myths out there about the accreditors and about the timing of surveys. Once an organization makes a decision to submit an application for Joint Commission accreditation, the organization actually tells us what month they want to be surveyed. That is, what month they're going to be ready to be surveyed. So we give the organization the latitude to predict for us when they think they're going to be ready. There is a myth out there that the accreditor can show up the day after you apply. Again, I can't speak to the other accreditors, but The Joint Commission would never do that. We would conduct our survey around the time that the organization said that they would be ready. Obviously, it's an unannounced survey, and so there's a good deal of variability in there. But as far as the subsequent survey, we would honor the organization's wishes, relative to their preparation time.

Kolbe: First of all, as everybody should know, all surveys are unannounced. Let's say you submit or we receive your application today. We do have a process. We have to review a lot of documents that the supplier has to submit with their application, not just the application itself. They have to answer survey preparation questions that are in the standards manual. This is a means by which suppliers can demonstrate their performance with each and every standard, and we do an assessment on this. We have an electronic scoring program, so we start the assessment off-site. We look at the documents that they submit to us. We also ask that they submit many different documents.

We can do a lot of this off-site. That slows down our clock and, better yet, minimizes the amount of disruption in that company's business, because we generally can get our surveys done in 1 day at each location, and sometimes even less if the supplier really had his act together and demonstrated conformance to the standards.

So, an off-site survey will include verification of what they said they were doing on paper, and we're going to verify that. We'll be interviewing people. So that process, what we call the off-site assessment—going through all the documents—takes some time. As soon as that is done—and it could take a few days depending on our backlog, it might be a couple of weeks before we can get to it—then we start scheduling the surveyor.

Again, the surveys are unannounced. We cannot tell the supplier when we are coming. However, in our policies and procedures, we do say that the survey will be done within 6 months after we have approved their application. So it could be a month after they send in their application or after we've approved it—or it could be 3 months or 4 months. But we will do it within 6. We also have informed CMS that we will guarantee that all who submit applications in a timely manner, if they're participating in the competitive bidding process, will be put at the top of the pile. So, since January 14, 2009, is the deadline for that, we will make sure that we will not only get the survey done, but that they will have their accreditation certificate—if they are awarded accreditation. We can't guarantee that, but we will get that certificate in by January 14, 2009. That's only for the round two competitive bidding folks.

After the survey is done, we do get a lot of calls asking, "When am I going to know?" Well, we also say in our policies and procedures that it can be 6 to 8 weeks. It's just going to depend on the backlog. It could be a lot sooner to get that final accreditation certificate decision/notification letter.

Nicholas: The average amount of time it may take, from start to finish, is 6 months. Providers everywhere should be looking at accreditation and the choices that they're going to be making, setting aside time and knowing that time needs to be available to get through the process.

Thompson: Are consultants needed to survive the accreditation process?

Kolbe: We don't believe that a consultant is needed for a supplier to "survive" the accreditation process, as you say. If suppliers have or get their procedures in place, they can successfully meet the standards. Who's in a better position to know what they need to do than they themselves? I have people calling me and saying that they want somebody to come in and do this for them. Well, yeah, they could pay several thousand dollars for somebody to do this for them. However, when we come on-site and they don't know anything that the consultant did for them, they are going to be really out of luck. Because we do a lot of interviewing, making sure employees know about the policies and procedures. And I don't mean just know about where the manual is. I mean, know them.

Greg Thompson: What happens to accreditation when a provider sells a company or is acquired by another organization? As a follow-up, if a provider adds a new service, is it automatically accredited until the time of the next survey?

Kolbe: The answer to that is no. That is, if the company is sold and bought by somebody else, accreditations are not transferable, plain and simple. The new owners will have to reapply for a new Medicare billing number or NSC number, as they're called. I would urge any buyers that are anticipating buying an existing DME company to contact CMS to find out if the Medicare billing numbers are transferable, because I don't know the answer to that question. What I do know is that the accreditations are not transferable. So, regardless, even if they inherit the other company's or previous owner's billing number, they cannot bill for Medicare until they get their new company accredited.

There are a lot of reasons for this. For example, the new owners may have never been in the HME/DME business before, and if they don't know anything about the standards or how to apply them, what guarantee is there that they're going to meet the standards? So that's the reason for a brand-new accreditation.

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As for if they provide a new product category or a new service, the first thing is that they are required to notify the National Supplier Clearinghouse and find out if they have to submit an amendment to Form 855F, which is the application that any supplier has to submit to the NSC to get a Medicare billing number. So, they need to find that out from CMS, because we don't have the answer to that.

If the supplier is automatically accredited for the remainder of the term—if they're adding a new product category or service—that is something that we will determine on a case-by-case basis here at CARF. We do have what are called supplemental surveys, but we definitely urge the supplier to contact us, and we will discuss the options with them.

Thompson: As HME providers are getting accredited, what are the questions that you're hearing most?

Floro: We hear consistently that organizations want to know what resources the accreditors will provide so they can successfully achieve accreditation. I think that the organizations are now sitting in a place where they now know they have to be accredited, so how can they get from point A to point B. For instance, at The Joint Commission level, when organizations ask that question, we provide them with all of the resources that we have in our house that can help them through accreditation. We have program leadership, for instance, myself included, who have either owned or managed DME companies. So we have industry expertise here at the program leadership level, and we can help our organizations, either through phone calls and, at times, on-site. When we meet [attendees from] organizations at Medtrade, for example, or at state meetings and national meetings, we can converse with them one-on-one and help them to understand how they can go about meeting the standards without being so prescriptive as to become consultants.