Strengthening Oversight of Accrediting Organizations

By Tiffany Ferguson, LMSW, CMAC, ACM, FCM

The Centers for Medicare & Medicaid Services (CMS) recently finalized changes to strengthen its oversight of Accrediting Organizations (AOs), reaffirming that organizations granted deeming authority must consistently evaluate hospitals’ adherence to the Medicare Conditions of Participation (CoPs).

While the announcement may initially appear to be directed solely toward AOs, I believe that its implications extend much further. For hospitals, this rule represents an opportunity to reexamine how regulatory compliance is interpreted, operationalized, and ultimately measured across the healthcare industry. It is not uncommon that I witness variations among hospital organizations that focus more on accreditation behaviors from the AO and their provided standards, rather than a clear understanding and adherence to the actual CoPs.

AOs serve a critical role within the Medicare program.  The CMS recent rule reinforces that this responsibility is a public trust, and emphasizes the need for increased oversight and more consistent survey performance among AOs. The intent seems straightforward in that hospitals participating in Medicare should be evaluated against the same federal requirements, regardless of which AO conducts the survey.

As someone who spends much of my time conducting operational assessments in hospitals throughout the country, I welcomed this announcement. Over the years, I have had the opportunity to work alongside organizations accredited by the two major national accrediting bodies. One observation has become increasingly difficult to ignore: I can often identify a hospital’s AO before anyone tells me, simply by observing operational workflows.

For example, I observe how the utilization management (UM) plan recognizes medical necessity, and how Important Messages from Medicare (IMMs), Medicare Outpatient Observation Notices (MOONs), and other required beneficiary notices are delivered and tracked. I evaluate utilization review committee operations, physician advisor engagement, documentation expectations, and compliance monitoring.

Very quickly, patterns begin to emerge. Some organizations devote tremendous effort toward one aspect of compliance while giving comparatively little attention to another equally important Medicare requirement. Other hospitals demonstrate exceptional operational rigor in areas that receive relatively little emphasis during surveys performed by another AO.

This variation is understandable, to a point. AOs have historically developed different educational materials, survey methodologies, and operational expectations. However, hospitals participating in Medicare are all ultimately responsible for complying with the same federal regulations.

The CoPs do not change because a hospital selected one AO instead of another. To be clear, this is not intended as criticism of any individual AO.

Each has invested tremendous effort into improving quality, patient safety, and regulatory compliance. However, the practical reality is that hospitals often adapt their compliance programs to align with what surveyors consistently evaluate, as well as from prior citations they have received.

When certain regulatory requirements receive more emphasis during one type of survey than another, organizations naturally devote additional education, auditing, and operational resources toward those areas. Over time, this can create meaningful differences in how hospitals implement mechanisms to adhere to identical federal regulations.

These operational differences should prompt an important question: are hospitals responding primarily to federal regulations, or are they responding to the survey emphasis they have historically experienced? Ideally, hospitals accredited by different organizations should demonstrate fundamentally similar compliance with these requirements, because they are ultimately being measured against the same federal expectations.

Organizations should be building sustainable compliance programs grounded directly in the CoPs and then supported by the interpretive guidelines. CMS’s strengthened oversight of AOs has the potential to move the industry closer to that goal.