The Conditions of Participation (CoPs) from the Medicare program are a prime focus of compliance for both hospitals and Critical Access Hospitals (CAHs). Hospitals and CAHs have different CoPs although there are some similarities. The purpose of this workshop is to provide an overview of the CoPs, the interpretive guidelines for surveyors, and to delve into current issues surrounding the CoPs.
The CoPs for both hospitals and CAHs are quite detailed, complex and span a significant range of concerns. The CoPs for both hospitals and CAHs are embodied in the CFR (Code of Federal Regulations). There are two appendixes in the SOM (State Operations Manual) that are devoted to providing surveyors with guidance concerning auditing hospitals to make certain that compliance is being maintained. Updates to the CoPs occurs on a regular basis and keeping up-to-date can be a challenge. The greatest obstacle is to be able to withstand an audit for adhering to the CoPs. Given the scope and detailed nature of the CoPs, the ability to withstand audits without some penalties is difficult. See also EMTALA (Emergency Medical Treatment and Labor Act) for similar processes.
- What are these CoPs?
- Why do hospitals and CAHs have different CoPs?
- What are these interpretive guidelines?
- Where can I find more information on the CoPs and associated interpretive guidelines?
- What types of issues are contained in the CoPs?
- What is the primary focus of the CoPs?
- What do hospitals need to do in order to prepare for CoP audits?
- Do physicians and nursing need be involved in the CoPs?
- Is EMTALA involved with the CoPs?
- What is the auditing/surveying process for the CoPs?
- Are there special CoPs for different types of hospitals?
- To review 42 CFR §482 – Hospital CoPs
- To review Appendix A of the SOM
- To review 42 CFR § 485 – CAH CoPs
- To review Appendix W of the SOM
- To understand terminology and requirements for CoPs
- To appreciate CAH COPs and how they differ from PPS hospitals.
- To understand special requirements for physicians and practitioners.
- To have knowledge of special concerns about EMTALA.
- To appreciate how the provider-based rule (PBR) affects the CoPs.
- To understand the requirements for physician supervision.
- To understand the requirements for utilization review.
- To understand the need to at least annually review the CoPs for compliance.
- To review current problems with the CoPs and on-going guidance.
- PPS Hospitals
- Reimbursement – DRGs and APCs
- Cost Report Utilization
- Critical Access Hospitals
- Cost-Based Reimbursement
- Organizational Structuring Requirements
- Cost-Reporting Process
- PPS Hospitals
- Comparison of CHA to PPS Hospital CoPs
- CAH – Rural Setting
- CAH – Rural Networks
- State Operations Manual & Audit Information
- Process for Auditing/Surveying
- Special Issues for Both CAH and PPS Hospitals
- Review of CoPs
- Definitions and Terminology
- Personnel and Personnel Qualification
- Status, Location, Certification and Accreditation
- Emergency Services
- Physical Plant
- Organization and Staffing
- Services and Clinical Records
- Periodic Reviews and Quality
- Physician Credentialing
- Utilization Review
- Telehealth Services
- Special Related Issues
- Different Types of Hospitals and Hospital Units
- Conditions for Payment (CfPs)
- Provider-Based Rule
- Observation and IP Status
- Physician Supervisory Requirements
- Non-Physician Practitioners
- Sources for Further Information
- Coding Personnel
- Billing and Claims Transaction Personnel
- Nursing Staff
- Outpatient Service Area Personnel
- Chargemaster Coordinators
- Financial Analysts
- Compliance Personnel
- Other Interested Personnel
About the Presenter:
Duane C. Abbey, PhD, CFP, is a management consultant and president of Abbey & Abbey Consultants, Inc., a consulting firm specializing in healthcare and related areas. Duane earned his graduate degrees at the University of Notre Dame and Iowa State University and has more than 20 years of experience as a consultant. Dr. Abbey works extensively in all areas relating to compliance reviews, coding, billing and reimbursement with particular emphasis on the chargemaster and outpatient payment. His consulting activities include hospitals and physicians based clinics.
In addition to his consulting practice, Dr. Abbey also teaches workshops and makes presentations on a regular basis. He has taught at the University level and speaks nationally. He is a regular presenter for hospital associations, medical societies, Boards of Trustees and various other organizations and groups. In addition, professional societies such as HFMA use Dr. Abbey’s services to present seminars and workshops.
Dr. Abbey is a nationally recognized expert in payment systems. A special area of expertise includes APGs/APCs. He is recognized as the leading expert in the nation in APGs/APCs by the thousands who have attended his seminars, read his publications and/or contracted for his services. Attendees at these seminars over the years have included personnel from hospitals, clinics, integrated delivery systems and multiple consulting firms.
Dr. Abbey is also the author of numerous articles and books including: Compliance for Coding, Billing & Reimbursement, Outpatient Services: Designing, Organizing & Managing Outpatient Resources, ChargeMaster: Review Strategies for Improved Billing and Reimbursement, Ambulatory Patient Group Operations Manual, published by McGraw-Hill and Non-Physician Providers: Guide to Coding, Billing & Reimbursement, Chargemasters: Strategies to Ensure Accurate Reimbursement and Compliance, and Emergency Department Coding & Billing: A Guide to Reimbursement & Compliance published.
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