CMS Certification Process: A Guide for Healthcare Facilities

It’s in any healthcare facility or residential care home’s best interest to uphold high-quality safety standards. Whether it means maintaining a safe environment or delivering and documenting best-practice care, high standards yield better patient outcomes. But did you know that being compliant with federal regulations benefits your budget, too?

To get reimbursed by state and federal programs, healthcare organizations must be compliant with health and safety regulations. This article will cover the accreditation and certification processes that enable organizations to participate in these programs. Use this guide as your CMS certification lookup tool to help you understand and maintain compliance within your organization.

What Is Certification?

Centers for Medicaid and Medicare Services (CMS) is part of the Department of Health and Human Services (HHS). CMS administers Medicare and Medicaid, along with other federal assistance programs.

• Medicare is a federal health insurance program for adults 65 or older, people with end-stage renal disease (ESRD), and certain young people with disabilities.
• Medicaid is a state assistance program that provides healthcare coverage to eligible low-income adults, children, elderly adults, pregnant women, and people with disabilities.

To participate in Medicare and Medicaid programs, healthcare organizations must meet the health and safety standards established by the Social Security Act. This is done during the CMS certification process, in which a State Survey determines whether a facility is compliant with federal regulations.

Who Gets Certified?

If you’re wondering how to obtain medicare and medicaid certifications, the first step is to enroll as an institutional provider, either as a “provider” or “supplier.”

• Providers are patient care institutions. They include establishments like hospitals, hospices, nursing homes, and home health agencies.
• Suppliers are facilities that provide diagnostic care or therapy. They may include laboratories, surgery centers, and clinics.

The process of becoming an institutional provider starts with getting an NPI number, which is an identification number given to providers to protect patient privacy. Then, an institution completes an enrollment application and pays a fee. The final step is to work with a Medicare Administrative Contractor (MAC), a private insurer with geographic jurisdiction to process claims. MACs manage provider claims, policies, and payments related to reimbursement.

Who Conducts Surveys?

State Survey Agencies (state and local agencies that work with CMS) may perform inspections, or surveys, on behalf of CMS. They carry out initial surveys and periodic resurveys for all providers and certain suppliers. The federal government also authorizes national accrediting organizations such as The Joint Commission (TJC) to perform surveys.

A process known as “deeming” determines whether an institution meets or exceeds Medicare standards. Upon completion of a survey, an organization receives a certification of compliance called Conditions of Participation (CoPs) or Conditions of Coverage (CfCs).

How to Get Certified

Certification is granted when a State Survey Agency officially says that a healthcare facility is compliant with federal regulation standards. To do this, they must meet the standards to be considered a provider or supplier in accordance with the Social Security Act. Qualifying institutions receive a CMS Certification Number (CCN). This number verifies that a provider is Medicare certified and the services for which it is certified.

The CMS credentialing requirements are confirmed throughout the certification process. Read about the steps for the process below.

1. Identifying Potential Participants

This involves identifying providers and suppliers that meet the requirements to participate in Medicare or Medicaid programs. Suppliers may include entities participating in Clinical Laboratory Improvement Amendments (CLIA).

2. Conducting Investigations and Fact-Finding Surveys

Surveys determine whether a healthcare facility is compliant with the 24 CMS CoP requirements. For on-site surveys conducted by TJC, standards are informed by patient safety indicators. They’ll look at factors contributing to:

• Infection control
• Patient rights and education
• Prevention of medication errors

During an on-site accreditation survey, professionals will meet with different stakeholders in your healthcare facility. Be prepared for them to speak with anyone from leadership team members to physicians and nurses.

Surveys conducted for CMS certification in nursing homes may determine whether a citation of non-compliance is appropriate. Surveyors use protocols and interpretive guidelines to assess a facility’s compliance with federal regulations.

3. Certifying and Recertifying

If an institution passes the inspection, notification of certification goes to federal or state agencies. This indicates that providers or suppliers are qualified to participate in federal or state programs.

4. Explaining Requirements

Providers and suppliers are advised on federal regulations that enable them to qualify to participate in Medicare/Medicaid programs. They’re given information on the standards of care consistent with CoPs and CfCs. Certain types of facilities, such as skilled nursing facilities, must meet staff education requirements. This involves staff and resident educational programs, which are mandated by the Social Security Act.

Stay in the Know About the Latest CMS Requirements

CMS certification may feel like a long and daunting process, but learning about it and related topics doesn’t have to be. Get the expertise and answers you need, when you need them, with our free compliance insights and resources.