In March 2020, the Centers for Medicare & Medicaid Services (CMS) introduced the Hospitals Without Walls initiative under the Public Health Emergency (PHE) to allow certain providers flexibility in the types of services and locations where those services were provided. This waiver applied to hospitals, Critical Access Hospitals (CAH), independent freestanding emergency departments (IFED), and ambulatory surgery centers (ASC).
Under this initiative, hospitals and CAHs were able to provide services in areas not typically considered by CMS as part of the facility. For example, hospitals were permitted to provide hospital services at remote locations, like hotels or community facilities. This was intended to allow hospitals to better manage COVID-19 surges. During the PHE, CMS expressed the expectation that hospitals utilizing this flexibility were required to control and oversee all services being provided at these locations. When the PHE ends on May 11, 2023, all services provided outside of designated areas will need to be moved or ceased. Hospitals and CAHs are expected to immediately comply with Hospital and CAH Conditions of Participation at 42 CFR Part 482 and Part 485, Subpart F by providing services only within their hospital departments.
IFEDs were allowed by CMS to reenroll and provide hospital services. Additionally, ASCs were allowed to temporarily become certified hospitals and provide hospital services. After the end of the PHE, IFEDs' Medicare certifications will end, which will require them to immediately cease hospital services. ASCs will have two options: (1) satisfy the certification standards to operate as a hospital under 42 CFR Part 482, or (2) revert back to operating solely under ASC status.
ASCs that choose to continue to operate as a hospital, must submit form CMS-855A on or before the conclusion of the PHE. This will begin the enrollment and initial certification process. An initial survey must be completed by the Accreditation Organization (AO) or State Agency (SA) to confirm compliance with all applicable Conditions of Participation under 42 CFR Part 482 and Part 485, Subpart F. Upon completion of the survey and satisfaction of all Conditions of Participation, CMS will issue a final determination letter for Medicare participation.
ASCs deciding to revert back to operating as an ASC must notify the applicable CMS Survey and Operations Group (SOG) location of its intent to terminate its temporary hospital status in writing on or before the conclusion of the PHE via email or mailed letter. Upon receipt, the CMS SOG will terminate the temporary hospital CMS Certification Number (CCN) and provide the entity with a tie-out notice to the applicable Medicare Administrative Contractor (MAC). The MAC will then deactivate the temporary hospital billing privileges and reinstate the original ASC billing privileges. After temporary hospital enrollment is terminated, the ASC must immediately comply with all applicable ASC federal participation requirements, including the Conditions for Coverage.
In order to ensure compliance following the end of the PHE, organizations should determine if they are utilizing these waivers. If so, the following steps will assist in addressing compliance risks after the PHE:
- Determine if the organization is utilizing these waivers and work with leadership to decide if the ASC will revert back to an ASC or take the steps necessary to operate as a hospital. The necessary forms should be completed and submitted and reflect the decision.
- Identify the services that are being provided in temporary locations and ensure staff are aware of what services are no longer allowed.
- Develop a plan for transitioning those services within hospital departments.
- Identify and develop any training and communications necessary.
- Work with the appropriate operational areas to ensure that changes are made to comply and that billing is accurate.
Overall, hospitals, CAHs, and ASCs must quickly pivot to ensure compliance with CMS regulations. Compliance departments in all organizations should partner with operations to ensure a smooth transition out of the PHE. Organizations that have utilized this initiative should not wait to make changes until the end of the PHE and instead should take immediate measures to prepare for a shift in medical care.
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