Surveyors spill beans on most common reimbursement, records mistakes
Outpatient facilities seeking acceditation more than doubles
Increasing numbers of outpatient facilities — more than double for one organization — have opted for accreditation as the health care industry increasingly emphasizes quality, officials with two national accreditation organizations say.
The Accreditation Association for Ambulatory Health Care (AAAHC) in Skokie, IL, has definitely seen an increase in outpatient facilities seeking accreditation, says Cathy Holmgren, MBA, RN, executive deputy director. The number of facilities seeking accreditation has more than doubled in the last two years, Holmgren says. "So many payers are looking for accreditation as one sign that an organization runs a good shop," she says.
Another trend pushing the surge in interest in accreditation is that some state governments are downsizing and therefore don’t have the staff resources to devote to state surveys. They are accepting proof of compliance in surveys by independent accrediting bodies, Holmgren says.
Both the Joint Commission and the AAAHC have deemed status, meaning they can serve as surveyors for Medicare. Ambulatory surgery centers and hospital outpatient facilities can choose to have their Medicare survey conducted by federal government officials or by one of the accreditation organizations.
"Quality care is at the level of the provider, and the accountability for quality increasingly is mandated," says Sam J.W. Romeo, MD, MBA, chairman of the committee for surveyor training and education for AAAHC.
"Accreditation is one of the most objective indications of outcomes," Romeo says. "It gives payers a sense of quality assurance from an external perspective."
Romeo also is the president and chief executive officer of University Affiliates IPA in Alhambra, CA, and professor of family medicine at the University of Southern California School of Medicine in Alhambra.
"I think accreditation is a credibility statement," says Beth A. Boyd, RN, clinical director and educational coordinator of the Breast Center in Marietta, GA. The center, which is accredited by AAAHC, is a private practice of surgeons who specialize in breast procedures.
"Accreditation shows the surgery center is intent on good quality care," Boyd adds.
How to avoid accreditation problems
Outpatient facilities have found that accreditation is also a way to help them prepare for state and federal mandates, which in some cases are even more stringent than the independent accrediting bodies, says Ann Kobs, MS, RN, former director of the department of standards for the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. Kobs now is sentinel event specialists for the Joint Commission.
Facilities that seek accreditation, particularly for the first time, might find it difficult to avoid some of the more common bear traps, such as maintaining record confidentiality. (See story on confidentiality, p. 83.) Outpatient Reimbursement Management asked Holmgren, Kobs, and some outpatient facility directors to discuss problem areas outpatient facilities experience during a survey.
Here are some potential problem areas and tips on how you can avoid them:
• Following their own policies.
"This is a lot of work, and you have to keep your staff up to date with your policies," says Jerry Henderson, executive director of the SurgiCenter of Baltimore in Owings Mills, MD. The center, which is accredited by AAAHC, handles about 11,000 procedures a year.
Facilities must comply with their own written policies. If these policies are changed, the policy manual should be immediately updated.
All employees should know your policies, especially the ones that apply to their jobs.
"It doesn’t do you any good to have your policies in place if your staff doesn’t know they’re there and employees are not following them," Henderson says.
A surveyor, for example, may pull aside an employee in your department and ask him or her what the policy is for sending out notices on late payments. The employee had better know the answer.
SurgiCenter posts various policies each month and has employees sign a log showing they read it. When there’s a new policy, it’s circulated to all employees, and again they each sign off on it, Henderson says.
• Handling reimbursement issues.
AAAHC surveyors will review a facility’s reimbursement records only partly to see whether the facility is compliant with standards, Holmgren says.
"There should be a system of approval on accounts receivable and payable," Holmgren says. "There should be an authorization process that only certain people are identified as being able to write checks."
The surveyor also will check the center’s rates to make sure patients and payers are charged a rate according to policy. And the surveyor will examine the center’s financial statements, income statements, balance sheets, and patient volume to see whether the center is billing adequately, Holmgren says.
The AAAHC administration chapter includes a policy that the organization has implemented fiscal controls on each of the following:
— authorization and record procedures that are adequate to provide accounting controls over assets, liabilities, revenues, and expenses;
— policies and procedures for controlling accounts receivable and accounts payable and for handling cash and credit arrangements;
— rates and charges for services.
Occasionally an AAAHC surveyor will find a facility that doesn’t have an operating budget. Nothing is planned, and there are no controls on what is spent. Instead, each year the facility turns its records over to an accountant to find out how well it did, Holmgren says. "That would be non-compliant with our standards," she says.
• Presenting thorough documentation.
Facilities should be thorough, timely, and accurate in all documentation. This includes making it easy for physicians to complete their records, Boyd says.
The Breast Center’s medical records department does not wait for physicians to call and ask them to pull records on a patient who is about to undergo surgery. Instead, the center closely watches the surgery schedule and then pulls charts for the physician before being asked to do so, Boyd says.
Records also must be legible, Kobs says. "You wouldn’t believe how messy they can be."
This does not mean the records must be on computer, Kobs adds. But if some of your records are handwritten, you might expect that a surveyor will hand a page to an employee and ask whether the employee can read it.
Joint Commission standards about documentation include the following:
— The organization takes steps to ensure that the data are complete, reliable, valid, and accurate on an ongoing basis.
— Decision makers and other appropriate staff are educated and trained in the principles of information management.
— Information-management processes allow data and information to be combined from various sources.
— The organization uses external databases and resources as necessary to meet its information-management needs.
• Meeting deadlines.
Record timeliness is important, Kobs and Holmgren say. A rule by thumb is that physicians should describe the procedure on a written chart within six hours after surgery, Kobs says.
If a facility has delinquent medical records (which are records that are not completed within 30 days), this could be a problem, Kobs says.
Joint Commission surveyors will ask a facility to record the average monthly delinquent records for the past four quarters. If the total is even 2% of all records, this problem could affect the organization’s accreditation, Kobs says.
SurgiCenter of Baltimore keeps reports up-to-date by having physicians dictate the reports by telephone. Next, the reports are transcribed and signed, Henderson says.
"If we have someone who is delinquent, then we handle that on an individual basis," Henderson adds. "But we really don’t have any trouble with that."
Facilities might want to consider electronic medical records, which are faster and have more security controls over the physician’s signature, Holmgren says.
"If it’s electronic, then nobody else can apply that physician’s signature except the physician," she says.
Sources
For more information on the accreditation process, contact:
• Beth A. Boyd, RN, Clinical Director and Educational Coordinator, The Breast Center, 702 Canton Road, Marietta, GA 30060. Telephone: (770) 428-4486, ext. 203. Fax: (770) 425-6008. E-mail: [email protected].
• Jerry Henderson, Executive Director, SurgiCenter of Baltimore, 23 Crossroads Drive, Owings Mills, MD 21117. Telephone: (410) 356-0300. Fax: (410) 356-7505. E-mail: [email protected].
• Cathy Holmgren, RN, MBA, Executive Deputy Director, Accreditation Association for Ambulatory Health Care, 9933 Lawler Ave., Skokie, IL 60077. Telephone: (847) 676-9610. Fax: (847) 676-9628. World Wide Web: http://www.aaahc.org. E-mail: [email protected].
• Ann Kobs, MS, RN, Sentinel Event Specialist, Department of Standards, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5900 or (630) 792-5000. Fax: (630) 792-5942. World Wide Web: http://www.jcaho.org.
• Sam J.W. Romeo, MD, MBA, Professor of Family Medicine, University of Southern California School of Medicine, 1000 S. Fremont Ave. A-11, Alhambra, CA 91803. Telephone: (626) 943-1040. Fax: (626) 943-1090. E-mail: [email protected].
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