At long last, the big day is here: opening day for your new surgical facility. There's only one small problem. You're still waiting for the state department of health to inspect your facility and give you a Medicare provider number. Without it, you're pretty much unable to get paid for cases. I've seen some new facilities wait eight months for their state inspection, a delay some never recover from. Those that do play catchup for years.

Don't let this happen to you. Surgery centers accredited by a national accrediting body with deemed status can get their Medicare provider numbers as soon as a month after they open. Find out how this little-known accreditation program can make your facility profitable sooner than you might have thought possible.

Shortcut to a provider number
Congress created deemed status in December 1996 to cut through the backlog of state ASC surveys that were (and still are) preventing new centers from treating a single Medicare patient for months while they waited for the state surveyor to show up and christen them with a Medicare provider number.

Deemed status doesn't replace the required state survey, but it does let you begin scheduling Medicare patients the day after you achieve this status, generally within 31 to 45 days of opening. This means your facility could be profitable within three months of opening.

The Centers for Medicare and Medicaid Services (CMS) deems that the following accrediting agencies can perform surveys in its stead - the Accreditation Association for Ambulatory Health Care (AAAHC), the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Who's eligible for deemed status? According to CMS, that would be "any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization, has an agreement with CMS to participate in an ASC, and meets the conditions for coverage as defined by regulation."1

Now or later?
Undoubtedly, preparing for a deemed status survey is a lot of work. Yet it's work that you'll have to do eventually for your state accreditation. So why not invest the time and money up front in order to begin Medicare reimbursement as quickly as possible? Whichever accrediting organization you choose to conduct your survey, be aware that your unannounced survey can only begin 30 days after official opening for business and after you've completed 10 surgical cases.

Here's a step-by-step process of preparing for your deemed status survey. By necessity, preparation should be a short and intense period focused on data collection and establishing the governance team. First, we'll discuss opening and accreditation.

Long before you open your surgery center (defined as the day you're available to answer phones and schedule cases), you should choose the deemed status accrediting agency you prefer to work with and that meets the needs of your partners and the community.

An important note: Pick the accrediting agency and complete the paperwork early in the construction phase. It will take you a good month to fill out the early-survey packet (tons of forms and the agency's deemed status survey manual). You'll need to review the manual and develop a checklist of all work that you must accomplish to pass the survey (downloadable at writeOutLink("www.outpatientsurgery.net/forms",1)). Also be sure to notify the accrediting agency that you're going for deemed status and approximately when you think you'll open. If you're running late with opening, notify the agency so it can move you to assure you get the early survey. If you wait until you're open for business to begin the paperwork, you'll be waiting months for the agency to come to your center.

On opening day, notify your selected accrediting agency to let them know you're open for business. This starts your 30-day wait for the agency's unannounced survey. Usually, one surveyor will conduct the deemed status survey over two days. Initially, you'll receive a Type 1 recommendation because you can't fully document performance improvement within the first 30 days of operation.

Six months later, the accrediting agency will return to make certain that all quality indicators are working properly and that your facility is meeting accreditation standards. Once this six-month follow-up survey is successfully completed, your center will be accredited for three years.

You'll be able to schedule Medicare patients as soon as the agency notifies you that you've passed the deemed status survey. Thirty days later, you can call your state department of health to learn if it has issued you a Medicare provider number. Until you receive your provider number, you'll have to hold Medicare bills. Usually, it takes an average of 45 days after the survey to receive your provider number.

Being able to provide services to Medicare patients can make a measurable difference between profit and loss in new surgery centers. Many managed care payers prefer to see that a new center has met CMS regulations before they'll negotiate contracts. During the first few weeks of operation, most surgical centers can only perform workers' compensation cases and PPO cases with out-of-network benefits.

Facility leadership
Now, let's review governance. A leadership structure is the foundation for the deemed status accreditation process. Governance usually consists of a board of directors and a medical executive committee (MEC). Minimally, this team will have by-laws governing the medical staff, the accreditation plan and corporate compliance plan.

Center developers will conduct initial MEC and board meetings, where members will be required to review all by-laws, rules, regulations, quality plans, policies and procedures before opening (download a meeting checklist at writeOutLink("www.outpatientsurgery.net/forms",1)). All meetings must produce minutes to be approved as written and signed by chairs of the MEC and board.

The facility's leadership is responsible for in-servicing all equipment and verifying all staff competencies. Begin this process the day each employee reports to work. Completion of the employee's orientation is essential and ties to completion of their personnel file. At the same time, initiate the employee's health file. Note that both files must be complete before the survey (an employee file checklist is downloadable at writeOutLink("www.outpatientsurgery.net/forms",1)).

Well, I'll be deemed
If opening under the deemed status process seems too labor-intensive and costly, let me tell you that in the long run it's financially worth the effort. Just focus on the end goals, which are getting a head start on making your center profitable, and sharpening your staff and your operations. Also consider the alternative, which can mean waiting months on state certification without being able to do a single case.

Reference:
1 Comprehensive Accreditation Manual for Ambulatory Care (CAMAC), section entitled "Conditions for Coverage of Ambulatory Surgery Centers," pp. 589 to 598. 1998 by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), One Renaissance Blvd., Oakbrook Terrace, IL 60181.