How to Streamline the Accreditation Process

The deadline to gain accreditation is right around the corner, with Sept. 30 being the cut-off date for providers to get certification. This is critical for most providers because they must be accredited in order to continue billing Medicare. Otherwise, they risk having their supplier number revoked.

Providers who wanted to get accredited should have started the process a long time ago. Given that the deadline to apply for accreditation was January 31 has passed (although CMS has since referred to the date as a “soft” deadline), providers should have already decided they would engage in the accreditation process and continue billing Medicare, or not.

The process is lengthy, and can consume four to six months on average. Much is involved. Providers must determine which accrediting organization they will work with, source additional support and consulting, train staff, integrate new processes and procedures, and finally undergo an unscheduled site survey in which officials from the accrediting organization will review the business to ensure it meets the required standards before awarding certification.

Now, the September deadline is nearly here and providers must scramble to ensure that they will be able to finish the accreditation process in time to ensure they will be able to preserve what is most likely the lion’s share of their funding. How can they streamline the process?

Understand what a site survey involves. Once a provider tells an accrediting organization that it is ready for its site survey, the site surveyor can come at any time. He or she will arrive unannounced and engage in a thorough, methodical process to ensure the business is compliant. The prospect of a “pop quiz” to determine the fate of your Medicare funding might seem scary, but if the provider engaged in all the necessary preparations to get accredited, it should not have much to worry about.

Be ready. At this point, a provider hoping to get accredited by Sept. 30 should be ready for a site visit. They should not be in a position where they are hoping to apply now and then only have three months to get ready. (If you find yourself starting at square one in the accreditation process now, you might want to read "How to proceed if you miss the accreditation deadline.") The accrediting organizations still have volumes of paper work that must be compiled just for the site surveys and final certification alone, so the likelihood that a provider can start from scratch now and get certified is very low. Simply put, the last bus is now at the station.

Have your documentation in order. Site surveyors will be looking to accurate records that adhere to accreditation standards. Take a second look at documentation of processes such as delivery, complains, licenses and similar items. This can get particularly tricky when it comes to state licenses. For instance, are you licensed to care for those oxygen patients that travel seasonally to other locations?

Ensure that all staff are on-board. At this point, all staff should have been brought into the accreditation process and educated on what they need to do in terms of business processes and documentation. All accreditation standards adherence must be part of the regular, day-to-day operations of the business and all staff must be in line with them.

This includes credentials. Staff must have the proper certifications and licensure, and those credentials must be up-to-date and in order. Moreover, credentialed staff must show they have sufficient CEUs, as well. Don’t forget that different states have different requirements as to which types of credentials or licenses are required to provide one kind of care or another. The accrediting organization will check that.

Double-check equipment. Since HME is an equipment-focal industry, make sure that your equipment meets all accreditation standards. Is it properly stored in the correct place? Are clean and dirty items segregated? Is there adequate space dedicated to specific items? These are questions the provider should be able to answer in a snap.

Keep a list. Your accrediting organization might provide a checklist of items that you should ensure are ready to go for a site survey. See if a list is available, and if so, obtain it and go through it. If not, review your accreditation standards and develop an internal list that reflects them. Then ensure your processes, documentation, staff and equipment line up with it.

Be covered in all instances. The period of July through September is when staff and management will be on vacation. What if a site survey comes when the key players are all relaxing poolside, without a care in the world? Simple answer: don’t let that happen. Make sure that there are staff members who have been deeply involved in the accreditation process present at all times, so stagger vacation schedules to accommodate that. You must always have on-staff experts who can point site surveyors to documentation, equipment, and other items reviewed during the survey process available at any time. If no one is there to work with the site surveyor, the provider will not pass.

Points to take away:

  • With the Sept. 30 deadline looming, a provider should be at the point where it is ready for a site survey.
  • Staff should be ready and should have all credentials up to date. Always have knowledgeable staff available to meet with the surveyor.
  • Ensure your documentation and all equipment is in order for the site surveyor to review.

Accrediting Bodies:

Accreditation Commission for Health Care Inc.

American Board for Certification in Orthotics and Prosthetics Inc.

Board of Certification in Pedorthics

Board for Orthotist/Prosthetist Certification

Commission on Accreditation of Rehabilitation Facilities

Community Health Accreditation Program

The Compliance Team Inc.

Healthcare Quality Association on Accreditation

Joint Commission on Accreditation of Healthcare Organizations

National Association of Boards of Pharmacy

National Board of Accreditation for Orthotic Suppliers



This article originally appeared in the July 2009 issue of HME Business.

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