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Proposed Rule Would Eliminate ASC Transfer Agreement Requirements

Analysis  |  By Revenue Integrity Insider  
   September 20, 2018

Ambulatory surgery centers would no longer be required to have a written transfer agreement with a hospital or ensure that all physicians performing surgery in the facility have admitting privileges.

This article first appeared in the National Association of Healthcare Revenue Integrity (NAHRI) Revenue Integrity Insider on September 19, 2018.

The Centers for Medicare & Medicaid Services is proposing to cut a broad range of requirements and reduce the required frequency of certain activities in the Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction proposed rule, with the stated purpose of furthering the agency's commitment to reduce the regulatory burden on providers while promoting patient safety.

The proposed rule would make changes to the Conditions of Participation for hospitals, critical access hospitals, rural health centers, federally qualified health centers, hospices, and ambulatory surgical centers (ASC). A number of the proposed changes focus on emergency preparedness policies, such as emergency plan and training requirements.

Related: How ASC Facilities Turn Their Smaller Operations Into Safer Operations

The CMS fact sheet outlines several proposed changes to hospital requirements, including:

  • Allowing multihospital health systems to have unified infection control programs and Quality Assessment and Performance Improvement programs for all hospitals in the system
  • Permitting hospitals to exercise discretion on when an autopsy is indicated under certain circumstances
  • Giving hospitals the flexibility to establish a medical staff policy that describes when a pre-surgery/pre-assessment for an outpatient could be used instead of a comprehensive medical history and physical (H&P)

Moving away from the current requirement of not more than 30 days for a pre-surgery/pre-assessment will allow facilities to determine which approach makes sense based on the needs of the individual patient, according to CMS' fact sheet. Although the current standard requirement would be lifted, hospitals would need to institute reviews for individual patients.

"The pre-surgical H&P will have to be vetted by the medical staff at every hospital/health system to determine what surgeries require comprehensive H&Ps versus those that don’t," says Valerie Rinkle, MPA, regulatory specialist with HCPro in Middleton, Massachusetts.

The proposed rule also includes clarification for behavioral health hospitals on the use of nonphysician practitioners, doctors of osteopathy, or medical doctors to document progress notes for the facility’s patients.

Hospitals should also review the proposed changes for ASCs as several of them could have a direct impact on hospitals. For ASCs, CMS is proposing to:

  • Remove the provision requiring ASCs to have a written transfer agreement with a hospital that meets certain Medicare requirements or ensuring that all physicians performing surgery in the ASC have admitting privileges in a hospital that meets certain Medicare requirements
  • Remove the requirement that a physician or other qualified practitioner conduct a complete H&P on each patient not more than 30 days before the date of the scheduled surgery

Hospitals and ASCs will need to thoroughly review how these proposals might impact them.

"I do have a concern about not requiring the ASC to have a transfer policy with a hospital and that the ASC physicians have privileges with hospital because this is likely to mean that any patient that does need to be admitted may have to go through the emergency department (ED) rather than being a direct admit to the hospital from the ASC," Rinkle says.

In particular, hospitals will need to evaluate their volume of direct admits from ASCs and whether the proposed removal of the ASC requirements could lead to increased operational burdens, greater financial burden for patients admitted through the ED, and patient safety concerns.

CMS' fact sheet positions the removal of these requirements as deleting duplicative patient protection measures, says John D. Settlemyer, MBA, MHA, CPC, assistant vice president, corporate revenue management/CDM support, at Atrium Health in Charlotte, North Carolina. However, to support its proposal to remove these provisions, on Page 28 of the proposed rule, CMS cited complaints it has received from the "largest ASC trade association" and multiple individual ASCs that a growing number of hospitals are declining to sign transfer agreements with competitive ASCs or declining to allow admitting privileges to the hospital by physicians who work in those ASCs.

In the proposed rule, CMS stated that it has attempted to work with hospitals and ASCs to resolve this issue but that several facilities were unable to reach a positive outcome. The agency further states that it does not believe removing these provisions would impact patient safety because ASCs are already required to have emergency response staff and that an ASC is expected to provide initial stabilizing treatment until the patient is transferred. CMS also stated in the proposed rule that EMTALA already requires hospitals to provide emergency care regardless of prior arrangements. This line of reasoning appears to fall in line with that used to support the proposed changes to reimbursement for excepted off-campus provider-based departments in the 2019 outpatient prospective payment system proposed rule.

Removing the requirement to complete a comprehensive H&P on every patient within 30 days of surgery would remove a burden from ASC providers, says Ronald Hirsch, MD, FACP, CHCQM, vice president of R1 RCM in Chicago.

"The proposed change would allow low-risk patients undergoing low-risk procedures to simply have a pre-surgery assessment on the day of surgery. This will allow ASC staff to spend less time chasing down paperwork and more time on patient care," he says. "It may also allow patients to schedule procedures sooner without having to visit their primary care physician, if they even have one. This will reduce expenditures for much of the superfluous pre-operative testing that is performed simply because it is required by policy without any benefit to the patient."

The rule includes the proposed addition of a requirement that ASCs establish and implement a policy that identifies patients who require an H&P assessment prior to surgery.

Nevertheless, hospitals could find themselves saving money if ASC physicians do not need to be credentialed with them, says Elizabeth Lamkin, MHA, CEO and partner at PACE Healthcare Consulting, LLC, in Bluffton, South Carolina.

"In my experience, this is a true burden on the medical staff office in terms of initial credentialing, re-credentialing, and Ongoing Professional Practice Evaluation," Lamkin says.

Organizations should review the complete text of the proposed rule, focusing on those sections that pertain to their specific facility types and services as well as those they work with frequently. And, although CMS might finalize many of the proposed changes, organizations will need to review and monitor state requirements which may remain more stringent than CMS', says Rose T. Dunn, MBA, RHIA, CPA, FACHE, chief operating officer of St. Louis-based First Class Solutions, Inc.

The proposed rule will be published in the Federal Register September 20. Comments can be submitted electronically, via email, regular mail, or express mail and will be due 60 days after the date of publication in the Federal Register.

Revenue Integrity Insider is a newsletter published by the National Association of Healthcare Revenue Integrity (NAHRI).


The proposal would affect hospitals, critical access hospitals, rural health centers, ambulatory surgical centers, and other facility types.

Several of the proposed changes for ASCs could have a direct impact on hospitals, so hospitals should evaluate their volume of direct admits from ASCs.

Hospitals could save money if ASC physicians do not need to be credentialed with them, a consultant says.

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