Obtaining Medicare certification is often one of the first hurdles that a new ambulatory surgery center faces, and at first glance, the task may seem almost simple. After all, the federal regulations governing ASCs that desire to participate in the Medicare program are only nine pages in length, very general in nature, and can be reviewed in less time than it takes to drink a cup of coffee. But like almost all things concerning the government, the process is much more convoluted than it first seems.

Why does the initial Medicare survey and the prospect of ongoing Medicare surveys strike fear into the hearts of many ASC staffs? The answer is simple. Even after performing thousands of surveys, the Health Care Financing Administration (HCFA) has never come up with a uniform rulebook outlining how the surveys are to be conducted, so it's almost impossible to prepare for them. Furthermore, the state health department representatives who perform the surveys rarely have any experience in an ASC setting. They may understand how things "used to work" in a hospital surgical setting, but they have very little idea of how an ASC operates and differs from a hospital.

Standards differ widely depending on geography. In California, a surveyor might deem it "against the rules" to launder linen at the facility, but a surveyor in Kansas may consider that practice to be perfectly acceptable. In Minnesota, a facility might be penalized for performing pain management procedures in pre-op or post-op areas (rather than in the OR); a Florida surveyor may accept this without question. National firms that own centers in different states find it nearly impossible to keep up with all the regulations.

Did you ever try to question Medicare surveyors when they deem that something violates the rules? Chances are, they won't be able to provide a specific citation (e.g. Rule # 257.496, Sect. A, paragraph g) to the actual rule-for the simple reason that there probably isn't one. And the most frustrating thing? They get away with it! Most administrators don't question surveyors about the specifics of a negative finding. They believe (not without reason) that upsetting the surveyor is akin to stirring the wrath of God-or, at the very least, ensuring that their facilities will never open. Thus, they nod their heads and acquiesce, no matter how illogical or crazy the determination happens to be.

There's no good reason they should do so. All accreditation agencies, including the Joint Commission on Accreditation of Healthcare Organizations, the Accreditation Association for Ambulatory Health Care, and the American Association for the Accreditation of Ambulatory Surgery Facilities have developed clear survey guidelines, and they require that their surveyors have ASC experience. Why shouldn't HCFA do the same? How can facilities improve or change if they don't know what to aim for?

It's time for facilities to demand fair, clear standards and knowledgeable surveyors. When HCFA complies, I think they'll find that most facilities are willing to play by the rules. They just need to know what they are.