Those who bill the Centers for Medicare and Medicaid Services (CMS) for treatment rendered to their patients must comply with a set of health and safety standards, referred to as Conditions of Participation (CoPs). The purpose of these standards is to promote a higher standard of quality for the services provided to patients.
Types of Providers Who Must Comply
Fundamentally, any provider who bills Medicare and Medicaid must comply with CMS’s standards, though specific types of institutions may have additional or separate standards. In general, the conditions of participation apply to the following:
- Home health agencies
- Ambulatory surgical centers
- Psychiatric hospitals
- Transplant centers
- Rehabilitations agencies
- Critical access hospitals
Some of the conditions that participating healthcare organizations must meet include the following:
- Compliance with federal, state, and local laws wherever applicable
- Informing patients of their rights under federal and state laws
- Establishing a process to promptly resolve patient grievances along with specific timeframes for review and response
- Inclusion of patients in the development and implementation of their plan of care
- Compliance with patient advance directives
This, of course is only a sampling of the regulations in force under CMS CoPs. Hospitals and other organizations must take great care to ensure compliance with the full extent of these conditions.
Penalties of Noncompliance
If an organization is audited and found to be in noncompliance with CMS standards, they may face severe penalties. The main penalty is termination from participation in Medicare and Medicaid programs, which can be a devastating blow to a healthcare provider. Providers can remediate noncompliance status by submitting a Plan of Correction (POC) within 60 days of the survey’s exit date.
Other penalties may apply depending on the type of provider. For instance, a skilled nursing facility could face a financial penalty of $1,000 to $10,000 per violation.
Participation Compliance Audits
CMS performs compliance surveys without forewarning, so you must be prepared at all times. For this reason, it is recommended that you perform a conditions of participation audit on your own terms to detect any discrepancies or violations before CMS does. An experienced health care law attorney can assist you with a participation compliance audit to find and repair problems ahead of time.