Strengthening CMS Oversight of Accrediting Organizations

Strengthening CMS Oversight of Accrediting Organizations

Accrediting Organizations (AOs) play an important role in determining whether healthcare providers and suppliers participating in Medicare or Medicaid programs meet health and safety requirements. Each year, CMS-approved AOs survey more than 9,000 healthcare providers for compliance with health and safety requirements. By achieving accreditation through a CMS-approved AO program, these facilities are "deemed" to meet all applicable federal participation requirements.

For CMS to approve an AO's program, their accreditation standards must meet or exceed the requirements and conditions under the Medicare or Medicaid programs to ensure patients receive quality and safe care. When CMS approves an AO program, the AO can perform surveys in lieu of State Survey Agencies (SAs). By taking on this role, AOs accept a "public trust" responsibility in their oversight of the nation's healthcare providers.

CMS identified several concerns about AOs' survey performance, such as:

• Providers and suppliers retaining their accreditation after they are terminated from Medicare or Medicaid programs for quality and safety concerns.
• Conflicts of interest arising from AOs providing fee-based consulting services to the providers and suppliers they accredit (often just before an accreditation survey), potentially compromising the integrity of the process.
• Inconsistent survey results due to AO standards or practices that differ from those of SAs (e.g., AOs notifying facilities before the date of their onsite surveys, which is against CMS policy).

CMS' annual Reports to Congress (RTCs) on AO oversight highlight the agency's concerns about AO performance. n response, CMS is committed to correcting deficient AO survey performance, strengthening oversight of AOs, reducing conflicts of interest, and establishing greater consistency in survey processes and standards to improve patient care and ensure safety in participating facilities.

Notice of Final Rule Publication

CMS released a Notice of Proposed Rulemaking (NPRM) on February 8, 2024, revising its AO requirements to bolster AO oversight and ensure providers meet health and safety standards so that patients receive high-quality, safe care from our nation's healthcare facilities. CMS addressed the public comments received on the 2024 NPRM and is publishing the Final Rule with comment period to strengthen its oversight of AOs that are entrusted with ensuring the quality and safety of patient care nationwide.

Provisions of the Final Rule

The Final Rule with comment period includes the following changes to CMS' AO requirements, which align with CMS' National Quality Strategy: https://www.cms.gov/medicare/quality/meaningful-measures-initiative/cms-quality-strategy

• Holding AOs accountable to the same Medicare standards and strengthening comparability of survey processes to those of SAs that also conduct surveys on behalf of CMS.
• Ensuring that AOs remain independent reviewers by addressing conflicts of interest and placing certain limitations on the fee-based consulting services AOs provide to the healthcare facilities they accredit.
• Preventing AO conflicts of interest by prohibiting AO owners, surveyors, and other employees, as well as their immediate family members that have an interest in or relationship with a healthcare facility accredited by the AO, from participating in surveys, having input into the survey results and involvement in pre- or post-survey activities of that facility, and from having access to survey records related to that facility.
• Improving AO performance by requiring AOs with unacceptable performance measure scores, determined through a direct observation validation survey by CMS (a new process for monitoring AO performance established as a requirement in this rule), to submit a publicly reported correction plan to CMS.
• Improving consistency and standardization in surveys nationwide by more closely aligning AO survey activity requirements and staff training with those of SAs.

Additional changes in this Final Rule with comment period will reduce the burden on providers, strengthen survey policies, and increase the transparency of AO practices.

Affected AOs

Currently, CMS has approved nine AOs to survey and accredit Medicare-certified facilities for deeming purposes. The changes outlined in the Final Rule with comment period affect all AOs except those that accredit clinical laboratories and noncertified suppliers, which include suppliers of advanced diagnostic imaging (ADI), home infusion therapy (HIT), and diabetes self-management training (DSMT), as well as durable medical equipment suppliers and suppliers of prosthetics, orthotics, and supplies (DMEPOS).

To access the Final Rule, (CMS-3367-FC), visit https://www.federalregister.gov/