CMS Delays Enforcement of Physician Supervision for Critical Access Hospitals

2010 revisions to physician supervision

The final 2010 hospital OPPS rule included a "direct supervision" policy that requires a supervisory physician or non-physician practitioner (NPP) to be present on a hospital or CAH campus when outpatient therapeutic services are performed and immediately available to provide assistance and direction throughout the duration of procedures.

For services "in the hospital" or provided in designated on-campus provider-based departments, the supervising practitioner only needs to be on the campus, not in the department. However, many CAHs do not have physicians or NPPs on the campus at all times.

In some cases, CAHs do not have the budget to hire additional staff members to provide 24-hour supervision and in other cases, they are not able to find anyone willing to work in a rural location.

Another problem is the discrepancy between EMTALA requirements CAHs abide by and the physician supervision requirements, Shah says.

"As long as critical access hospitals have been abiding by EMTALA, they should be fine until we hear something further," Shah says.

CMS has not stated what level of physician supervision it will require CAHs to have this year. Physician supervision is critical for patient safety, but the level of supervision or the requirements around the level of supervision should hopefully come more in line with what the EMTALA rules already are, Shah says.

CAHs should consider having a policy that addresses CMS' concerns about the quality and safety of outpatient services, Hoy says. That policy should refer back to the CAH Conditions of Participation (CoP), which define what constitutes safe and appropriate care at a CAH and the availability of providers.

"CMS seems to be keying on the quality and safety of the services, so I think referring back to the Conditions of Participation on availability of providers and ensuring that their policies meet those requirements will demonstrate that they have considered the quality and safety of the care they are providing to their outpatients," Hoy says.

In its policies, a CAH board of directors may want to address these requirements, CMS' guidance on non-enforcement in CAHs, and the reasons they are unable to meet the requirements. The board can then specifically state the reasons it believes patients are receiving high-quality, safe care in its hospital, including that CoPs are met, Hoy suggests. This will provide documentation of the reason for lack of supervision if the hospital is later challenged

Moving forward

CAHs should not consider this temporary reprieve a free pass, Mackaman cautions. "They should begin to consider how they might meet the current regulations if the rule does not change in 2011."

Michelle A. Leppert, CPC-A, is managing editor for Briefings on APCs and APCs Weekly Monitor. She can be reached at mleppert@HCPro.com.