CMS Changes in the Conditions of Participation Requires Hospitals to Act

On November 18, 2011, the Centers for Medicare and Medicaid Services (CMS) updated its guidance to and, although briefly, dramatically changed who could order rehabilitation services at a hospital. Now hospitals must review the initial guidance, the revised guidance described below and update its policies to comply with CMS requirements immediately. Hospitals that provide rehabilitation services must ensure that the delivery of services conform with the CMS Conditions of Participation. One such standard requires for the rehabilitation services to be delivered under the orders of a qualified and licensed practitioner acting within the scope of his license and authorized by the hospital’s medical staff to order the services in accordance with the hospitals’ policies and procedures. Hospitals rely upon practitioners in the community ordering services to generate revenues. This Condition of Participation seemingly did not appear to restrict the hospitals ability to receive orders and provide therapy services.

However, the new State Operations Manual directed that the practitioner that orders rehabilitation services must have medical staff privileges to order such services. Processing a medical staff member though the credentialing process is an administrative procedure which verifies the licensure, credentials, experience, education and qualifications of the practitioner. This administrative process can take anywhere from 60 to 120 days. The time delay would impede the practitioners from being able to send patients to the hospitals for services. This new requirement to credential and privilege each practitioner who orders therapy services at the hospital caught many hospitals off guard.

Typically, hospitals receive orders for therapy services from licensed practitioners throughout the region. These practitioners often are not members of the hospital medical staff and instead are merely practitioners providing services in the community. Hospitals historically have not required practitioners who order a therapy service to engage in the medical staff membership or the credentialing process which enabled the hospitals to receive therapy orders from a wide array of providers. Requiring each practitioner to be a member of the medical staff and to complete credentialing could impede a practitioner’s willingness to use the hospital. Thus, when the orders for therapy services are restricted, the hospitals’ services decline along with its revenues.

Due to the potential financial and operational challenges associated with this guidance, professional associations, including the therapy associations contacted CMS to request revocation or modification of this guidance. On February 17, 2012, CMS issued new guidance to identify who can order hospital outpatient services. The guidance requires the practitioner to conform with the following:

(i) Be responsible for the care of the patient;
(ii) Be licensed in, or holds a license recognized in the jurisdiction where he/she sees the patient;
(iii) Act within his/her scope of practice under state law; and
(iv) Be authorized by the medical staff to order the applicable outpatient services under a written hospital policy that is approved by the governing body.

Under this guidance, the practitioner may be on the medical staff or may be in the community without medical staff privileges. If the practitioner is not on the medical staff then the hospital must have a policy to determine who is authorized to order the outpatient services. Therefore, the burdensome requirement of having all practitioners that send patients to the hospital go through the medical staff credentialing process has been lifted. Now, hospitals must ensure it has proper policies and procedures to confirm that ordering practitioners are authorized to order outpatient services in accordance with State laws.

A hospital wide policy should be approved by the governing board and the medical staff to affirmatively identify the practitioners authorized by the hospital to order outpatient therapy services. The hospital policy should ensure that the practitioners who are ordering these services are verified as licensed independent practitioners within the State. These individual practitioners should be tracked and a listing of the practitioners should be maintained by the medical staff office.

In addition, to support communication between providers, hospitals may consider requiring each practitioner that orders a service, to provide his or her contact information, including the fax number, e-mail or other means of transmitting the results. To support comprehensive treatment plans, when the hospital requires current contact information, the results of the therapy services could be communicated back to the ordering practitioner in a timely manner. Improved and timely communication may also reduce duplicate testing or services. Therefore, to support compliance with the intent of the CMS delivery of services standard, the hospital’s policy should address the following elements:

a. Identify the types of practitioners approved to order outpatient therapy services at the hospital.

b. Require for the practitioners to be licensed independent practitioners authorized to order services.

c. Identify methods of communicating the results of the therapy and the on-going continuing of care to the individual practitioners.

Each one of these factors should be identified and considered. All orders received from any and all practitioners should be maintained in the medical record. In addition, services rendered should be documented completely and accurately to support compliance with applicable laws and regulations.

In conclusion, in order to support compliance with the CMS Conditions of Participation, hospitals should promptly promulgate a policy to be approved by its governing body and medical staff. The policy must identify the proper practitioners authorized to order outpatient services and to facilitate the treatment plan for each patient. All of these initiatives are designed to improve communication, quality of care, and reduce the costs of services. This new requirement should not go unnoticed and should be addressed immediately by any and all hospitals who receive therapy outpatient service orders from practitioners within the community that are not members of their medical staff.

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