Presented by Jeff Linzer Sr., MD, FAAP, FACEP
Dr. Jeff Linzer simplified the complex healthcare regulatory environment. First, which agencies have oversight of healthcare, hospitals and healthcare providers? State agencies including nursing and pharmacy boards, Medicaid, and hospital licensing. Organizations such as the Joint Commission oversee hospital accreditation. Third party payors also have oversight affecting who gets paid.
The Center for Medicaid and Medicare Service (CMS) provides rules thru Medicare for hospital participation as well as fee payment policies. Even though we in pediatrics do not care for patients in the Medicare population, this is still very important to us. The CMS manual is often how hospitals determine who provides what services. The Medicare conditions of participation (CoP) define qualified personnel who can administer general anesthesia, regional anesthesia deep and MAC. “Qualified anesthesiologists, physicians other than anesthesiologists, dentists, oral surgeons, podiatrists (if appropriate under state law) and qualified non-physician anesthetist (CRNS, PAA) but NOT RNs. They leave it to the hospital to define who can perform minimal or moderate sedation or administer topical analgesia.
According to the CMS, anesthesia services must be well organized and under the direction of a qualified physician, but it does not say this has to be an anesthesiologist. Who directs anesthesia services is determined by the local, state and hospital accepted practice. Anesthesia services have to be integrated into the quality improvement processes of the hospital.
CMS addresses one provider performing both anesthesia and the procedure: The same physician performing the procedure may not also provide the general anesthesia. For moderate sedation, the same physician providing the procedure and moderate sedation may report both services. Dr. Linzer did not specifically state what CMS’s stance is on the provider simultaneously performing deep sedation and the procedure.
Although following the guidelines set in the CMS manual and many of the Medicare conditions of participation may be beneficial for patients, and therefore hospitals, at face value, hospital accreditation is also at stake. Hospital accreditation is required in order for a hospital to participate in Medicare and Medicaid (and therefore get paid). Accreditation can be done by the state or organizations authorized by CMS or a combination of the two. The goal of accreditation is to assure compliance with CMS conditions of participation. There are several organizations authorized by CMS to accredit hospitals: The Joint Commission (TJC) is probably the one most familiar to everyone and is the largest of all but there are others such as DNV Healthcare, Healthcare Facilities Accreditation Program and Center for Improvement in Healthcare Quality.
TJC has guidelines above and beyond CMS in order to be accredited by them. Some of these more stringent guidelines relating to anesthesia and sedation include: the pre-anesthesia/sedation H&P requirement is only met if the H&P is on the chart (transcribed, not just dictated) and hospitals must set standards, competencies and privileging requirements for those providing moderate and deep sedation although it doesn’t define what medications are used for each.
Penultimately, Dr Linzer clarified some commonly misused terminology.
- Licensure: Government agency authorizes a person to perform a particular service, may set a particular scope of practice beyond which the person is not approved to practice
- Certification: Nongovernmental agency endorses that an individual or organization has met certain standards within the scope of that agency (e.g. sedation provider course from the Society for Pediatric Sedation)
- Privileges: What hospitals give providers to perform specific types of care within their facility. If performing task outside their privileges, then the provider is “out of their scope”. Medical executive board has ultimate responsibility for assigning privileges
Third party payors “credential” individuals to bill for certain services within their licensed scope of practice. Providers may need to show specific competency in order to be permitted to bill those services. If a payor doesn’t credential you even though you are licensed in your state and privileged to perform that care at your hospital, you cannot get paid by that payor.
Finally, Jeff’s keys to regulatory readiness:
- Know which agencies are involved,
- What is needed to meet regulatory requirements,
- What is needed to meet hospital requirements, and
- How to be able to report your services to meet those requirements.
