Medicare conditions for coverage create administrative, financial burdens for ASCs

Centers must track adverse events and report strategies to improve the safety and quality of patient care.

Mark Packer

As ambulatory surgery centers compete for patients in a sluggish economy, they face a host of new regulations that add administrative burdens and increase costs.

Nearly 2 years since the Centers for Medicare and Medicaid Services revised and expanded Medicare conditions for coverage for ASCs, some economically stressed practices have struggled to comply with additional regulatory burdens.

Administrative functions and attendant costs may diminish the profitability of even the most robust ASCs, Mark Packer, MD, a partner in an ophthalmic ASC in Oregon, said in an interview with Ocular Surgery News. Marginally profitable ASCs, especially those that specialize in refractive surgery, face an uphill struggle amid a slumping economy and the administrative burdens created by the updated Medicare rules.

“It is really important to try to get a handle on that the best you can before making a decision about becoming a partner or not,” Dr. Packer said.

Although necessary amid the complexities of modern medicine, regulation may impede the delivery of quality care in some cases, he said.

“I am supportive, really, of the government as a regulatory entity,” he said. “Situations can arise in which these regulations can become somewhat onerous and difficult. It is well-intentioned, but I think it can be a roadblock to good care.”

Requirements for ASCs

In the revised 2009 CMS conditions for coverage, extensive changes and additions affect Medicare certification for ASCs. According to the Ambulatory Surgery Center Association, ASCs must develop and implement ongoing, data-driven quality assessment and performance improvement programs that show measurable improvements in outcomes and safety.

In addition, ASCs must measure, analyze and track adverse events, infection rates and other areas of patient care, devise and prioritize quality improvement strategies, and thoroughly document their efforts.

At Dr. Packer’s ASC, one half-time-equivalent nurse was hired to facilitate compliance with the new regulations.

“We definitely took a hit,” Dr. Packer said. “Our bottom line went down because our expenses increased.”

Office staff must work harder to meet quality improvement requirements, hold committee meetings and complete required documentation, he said.

In addition, some of the regulations are rigid and may adversely affect access to care. For example, same-day surgery is allowed only in emergencies. A patient who travels a long distance to the ASC would have to make another long round-trip to receive care.

“It really puts the physician in a difficult situation,” Dr. Packer said. “There is a conflict between what the regulations say and what we have always done, which is just do what is best for the patient and let everything fall into place. You can’t just do that anymore.”

Implementation, training

A final document with interpretive guidelines for surveyors was released on May 15, 2009, only 3 days before full implementation of the new conditions for coverage was required. Thus, surveyors had little time in which to train, Regina Boore, RN, BSN, MS, principal and CEO of Progressive Surgical Solutions, a consulting firm, said. The company conducted a mock survey for Dr. Packer and his surgical group.

“We knew what the new rules were, but not what Medicare expected to document compliance. So, we got that document, but even then, there were so many new surveyors all hired at the same time. Their training was limited,” Ms. Boore said.

Surveyors, consultants and ASCs now have a stronger grasp of the new and revised regulations, she said.

Failure to comply with the new conditions for coverage may result in an ASC losing Medicare certification.

“They have, in fact, decertified a number of facilities,” she said.

A condition-level deficiency is basis for decertification. A plan of correction must be submitted and accepted within 10 days, and the facility is resurveyed within 45 days to verify that the corrective action plan has been implemented. At that point, if there are still problems, certification can be rescinded, Ms. Boore said.

In retrospect, Dr. Packer expressed desire for more gradual implementation of the new rules.

“It would have been nice to implement these changes in a more gradual way to see what the impact would be,” Dr. Packer said. “In other words, start with a few surgery centers and see how they manage rather than roll out this new raft of regulations and just have everyone jump onboard and live up to this all of a sudden.”

Mock surveys, internal audits

Mock surveys are an effective strategy for uncovering problems and preparing a practice for an unannounced visit by a surveyor.

In performing a mock survey, Progressive Surgical Solutions sends two consultants to the client facility for a 1-day visit. The consultants observe the clinical operation and scrutinize personnel files, medical credentials, policies and procedures, meeting minutes, facility logs, and training records, Ms. Boore said.

“There is a long list of things that Medicare looks at when they come for an unannounced survey,” she said. “We mimic that process and follow up with a written report of identified deficiencies and recommendations.” Reports are typically between 20 and 75 pages long, depending on how extensive the deficiencies are.

Documentation is critical to having a clean survey, Ms. Boore said.

“If it isn’t documented, it didn’t happen, at least from [a surveyor’s] perspective,” she said. “Getting a handle on the documentation in a way that is user-friendly for the surveyors helps facilitate a smooth survey process.”

Dr. Packer’s surgical group performs monthly self-audits to prepare for external surveys.

“We are all out here trying to do the right thing but we are in kind of a vacuum,” Dr. Packer said. “Our answer to that has been to do internal audits. We audit ourselves every month. We are trying to make sure that if we did get audited, we would be OK. But you can never know for sure.” – by Bryan Bechtel and Matt Hasson

• Regina Boore, RN, BSN, MS, can be reached at Progressive Surgical Solutions, 13327 Bronco Way, Poway, CA 92064; 858-487-7515; fax: 858-487-5400; e-mail: rboore@progressivesurgicalsolutions.com.
• Mark Packer, MD, can be reached at Drs. Fine, Hoffman and Packer, LLC, 1550 Oak St., Suite 5, Eugene, OR 97401; 541-687-2110; fax: 541-484-3883; e-mail: mpacker@finemd.com.
• Disclosures: No products or companies are mentioned that would require financial disclosure.