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CMS Survey & Certification Guidelines
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Background The Social Security Act (the Act) provides for a system of quality assurance in the Medicare program based on objective, onsite, outcome-based surveys by federal and State surveyors. The survey and certification (S&C) system provides beneficiaries with assurance that basic standards of quality are being met by health care providers or, if not met, that remedies are promptly implemented. CMS Priorities Longstanding CMS policy makes complaint investigations, recertifications, and core infrastructure work for existing Medicare providers a higher priority compared with certification of new Medicare providers. CMS directs States to prioritize federal survey functions in four priority “Tiers.” Tier 1 consists of statutory mandates, such as surveys of existing nursing homes and home health agencies. Tier 4 consists of other important work, but work that is considered reasonable to accomplish only if higher priority functions can be accomplished within the federal budget limitations. Many provider or supplier types (such as hospitals, ambulatory surgery centers, hospices, and home health agencies), have the option of becoming Medicare-certified on the basis of accreditation by a CMS-approved Accrediting Organization (AO, such as Joint Commission) instead of a survey by CMS or States. In such cases, the applicants have an alternate route to Medicare certification via CMS’ acceptance of the AO’s accreditation. While the applicant will pay a fee to the AO for the initial survey, applicants may conclude that the benefits outweigh the expense, particularly the expense of time waiting for a no cost CMS survey. Similarly, clinical laboratory surveys are not subject to the CMS prioritization structure because the laboratories pay a fee to CMS for the laboratory certification work. For all initial Medicare surveys conducted by CMS or States, there is no cost to the applicant, but the resource limitations described here require that CMS adhere to a clear sense of priorities in conducting the work. Most initial surveys for providers or suppliers seeking to participate in Medicare for the first time are prioritized in a lower priority (Tier 4) for CMS and State survey agency (SA) work compared to complaint investigations and recertification of existing providers or suppliers. CMS Priorities for Surveys of Providers and Suppliers in Medicare Priority Exception Requests Access to Care Reasons: Providers or suppliers may apply to the State survey agency (SA) for CMS consideration to grant an exception to the priority assignment of the initial survey if lack of Medicare certification would cause significant access-to-care problems for beneficiaries served by the provider or supplier. The State SA may choose whether to make a recommendation to CMS before forwarding the request to the CMS Regional Office (RO). Tier 1 • Consists of statutory mandated surveys for Hospitals, Acute Care Facilities, Skilled Nursing Facilities, Nursing Homes and Home Health Agencies. Also, response to immediate jeopardy complaints Tier 2 • Other types of complaints. Tier 3 • ESRD Facilities – Due to the unique reliance of dialysis patients on Medicare, and the fact that there are no deemed accreditation options for ESRD facilities, we accord such facilities a higher (Tier 3) priority than most other provider or supplier types. States Agencies may prioritize the initial surveys within Tier 3 to offer a high Tier 3 status for initial surveys of dialysis facilities given the unique reliance on Medicare on the part of end stage renal disease patients. Per CMS Ref: S&C-08-13 dated March 7, 2008. • Initial Surveys of Rural Health Clinics (RHCs) and Skilled Nursing Facilities (SNFs) - Raised to Tier 3 Priority Per CMS Ref: S&C-08-13 dated March 7, 2008. • Transplant Centers –Transplant centers are accorded the higher Tier 3 priority because there are no CMS-approved accrediting organizations (AOs) for transplant centers. While this may change in the future, CMS has neither received nor approved any AO applications for transplant center accreditation to date. In addition, transplant patients (and donors) rely on Medicare in ways that other patients do not (such as special eligibility provisions for postoperative immuno-suppressive drug coverage when certain otherwise ineligible individuals receive transplants from a Medicare-certified center). Tier 4 Accreditation Options: Initial certifications of all provider/supplier types that have the option to achieve deemed Medicare status by demonstrating compliance with Medicare health and safety standards through a survey conducted by a CMS-approved accreditation organization is a Tier 4 priority. In light of the federal Medicare resource constraints, we consider the cost of initial surveys to be the lowest priority for the Medicare program for those provider and supplier types that have a deemed accreditation option in those States unable to complete the higher-priority Tier 1-3 work. Provider/supplier types with a Tier 4 priority for initial surveys because the have a deemed accreditation option include: • Ambulatory Surgical Centers • Home Health Agencies • Hospices • Hospitals • Critical Access Hospitals All Others: All other newly-applying providers/suppliers not listed in Tier 3 are Tier 4 priorities, unless approved on an exception basis by the CMS Regional Office due to serious health care access considerations or similar special circumstances (see “Priority Exception Requests” above). The affected Medicare providers/suppliers include: • Comprehensive Outpatient Rehabilitation Facilities • Long Term Care Units in Hospitals • Nursing Homes that do not participate in Medicaid • Outpatient Physical Therapy • Rural Health Clinics
Last Updated April 2009
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