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From Health Law Daily, January 22, 2015

CMS addresses physician presence, clarifies CAH services

By Anthony H. Nguyen, J.D.

Summaries of two Final rules and updates to the state operations manual (SOM), discussed in a CMS letter to state survey agency directors, were issued regarding revised requirements for critical access hospital (CAH) conditions of participation (CoP) related to: (1) responsibilities of doctors of medicine (MDs) and doctors of osteopathy (DOs) and (2) provisions of inpatient acute care services. CMS noted updates were made to the pertinent sections of the CAH guidelines found in the SOM, as well as federal regulations addressing: (1) pharmacy services; (2) infection prevention and control; (3) dietary services; (4) services under arrangement; (5) nursing services; and (6) rehabilitation services. CMS attributed the regulation updates as part of the process to bring the regulations into alignment with current accepted standards of practice (CMS Letter, No. S&C: 15-19-CAH, January 16, 2015).

Final rules. Two final rules were published by CMS that changed CAH CoPs. The first Final rule, titled “Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2014 Rates; Quality Reporting Requirements for Specific Providers; Hospital Conditions of Participation; Payment Policies Related to Patient Status,” (Final rule78 FR 50496, August 19, 2013) generally addressed additional payments of $1.2 billion to hospitals under the Inpatient Prospective Payment System (IPPS) for services provided during fiscal year (FY) 2014, which began on October 1, 2013.

Additional monies are paid to the approximately 440 hospitals that receive payment under the Long-Term Care Hospital Prospective Payment System (LTCH PPS) for services provided during FY 2014. The Final rule also implemented the first reduction in payments to disproportionate share hospitals (DSH) enacted in the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) as a result of a decline in the number of uninsured individuals (see Hospitals will see an increase in IPPS and LTCH payments in FY 2014 but may see lower DSH payments as a result of ACA adjustments, August 19, 2013)

The second Final rule, titled “Medicare and Medicaid Programs; Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction; Part II”, (Final rule79 FR 27106, May 12, 2014) amended Medicare and Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations in order to remove unnecessary or excessively burdensome requirements on health care providers and suppliers, and clarified confusing or conflicting regulations. The changes made to the Medicare and CLIA regulations are in response to Executive Order 13563, as well as CMS’ efforts to limit unnecessary costs and increase flexibility for providers (see Medicare regulations amended for efficiency, transparency, and burden reduction, May 12, 2014).

CAH regulations. As noted in the CMS letter, changes were made to CAH regulations at 42 C.F.R. Sec. 485, Subpart F, affecting designation and certification of CAHs; number of beds and length of stay; staffing and staff responsibilities; and provision of services.

Effective July 11, 2014, the following additions and revisions were made to the CAH regulations in Appendix W of the SOM:

  • The cross-reference to hospital swing bed services in Sec. 485.606 was revised to reflect the renumbering of the hospital regulation.

  • Section 485.631(b)(1)(v) was clarified to state that a CAH MD or DO must periodically review and sign a sample of outpatient records of those patients cared for by non-physician practitioners to the extent required by state law, occurring at least every two weeks.

  • Previous requirements that MDs or DOs be present in a CAH at least once every two weeks, under Sec. 485.631(b)(2), were changed to require the MD or DO be present for sufficient periods of time to provide medical direction. CMS recognized that many MD or DO functions could be performed remotely via electronic means and changed the time required to be on-site at a CAH to vary, depending on volume and type of service.

  • Requirements for CAHs’ patient care policies’ development under the advice of at least one individual not on staff with the CAH in Sec. 485.635(a)(2)was removed.

In place since October 1, 2013, the following additions and revisions were also made to the CAH regulations in Appendix W of the SOM:

  • Section 485.620(a) was revised to remove an outdated effective date after which a CAH may not maintain more than 25 inpatient beds used to provide either inpatient or swing-bed services.

  • Conditional language implying CAHs could optionally provide acute inpatient services under Sec. 485.635(a)(3)(vii) was removed.

  • Regulation changes in 2012, removing language referring to “direct” services a CAH must provide under arrangement, were misinterpreted to suggest that CAHs only provide outpatient services. Consequently, language was added to Sec. 485.635(b)(1) to require CAHs to furnish acute care inpatient services.

  • In order to avoid a different misinterpretation of furnished services, Sec. 485.635(c) was also revised to remove inpatient hospital care as a service that could be provided under arrangement.

MainStory: TopStory CMSLetters CoPNews CAHNews ProviderNews CMSNews IPPSNews ClinicalNews LaboratoryNews PartBNews

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