CMS Conditions of Participation Guidance

On May 10, 2021, the Centers for Medicare & Medicaid Services (CMS) provided clarification on the requirements outlined in the Interoperability and Patient Access Final Rule. The clarifying information consisted of frequently asked questions and a guidance document for state surveyors. While the new resources help answer some questions raised by hospitals, many health information organizations, including Health information Exchanges and Hospital Associations, are looking for additional guidance, as not all of their questions were explicitly addressed in the new Conditions of Participation (CoP) guidance documents. In turn, we have identified the requirements that seem to have caused hospitals the most confusion and recently hosted an interactive webinar with the Strategic Health Information Exchange Collaborative (SHIEC), to address the remaining questions.

The questions raised about CMS’ most recent Conditions of Participation guidance include:

  1. Does CMS require an e-notification if a patient is transferred from the Emergency Department to Observation?
    Emergency Department to Observation visits are considered “outpatient”. It is not a requirement under the Conditions of Participation to send notifications when there is movement between two different outpatient visits.
  2. Are hospitals required to send e-notifications when a patient is directly admitted into a hospital under observation status?
    Yes, CMS would expect a notification to go out in this instance.
  3. What support can HIOs provide to hospitals ahead of being audited for Conditions of Participation compliance?
    Aside from restating what the CoP regulations require, health information organizations can equip hospitals with simple, easily accessible, and straightforward reports that will help them gauge where they stand with compliance. These reports could highlight patient-triggering events that notifications should have gone out for with supporting detail on where the notifications went or why the notifications did not go out (e.g., consent issue). If a hospital gets audited, they will not have a month to pull this information together, so hospitals should have the ability to pull these reports together when they need it.
  4. If a patient opts out of an HIE, is the HIE required to still send an e-notification?
    HIEs may choose to allow patients to opt of sending e-notifications to their providers. HIEs have varying approaches to consent, and many use an “all-or-nothing” approach, which means if patients wants to opt-out of notifications being sent, they must opt-out of the HIE as a whole.
  5. When will state surveyors start auditing for the Conditions of Participation?
    CMS’ Conditions of Participation went into effect on April 30th, so they could be conducting compliance audits now.

Click here to access the on-demand webinar recording. 

Here's what hospitals need to know about CMS' latest Conditions of Participation guidance

Prior to the latest SHIEC webinar on Conditions of Participation guidance, Audacious Inquiry facilitated webinars for SHIEC members and health information organizations leveraging Audacious Inquiry’s services for Conditions of Participation compliance. Here is an overview of the key points that attendees gained from these introductory to Conditions of Participation sessions:

  1. Observation Status: Notifications are required for observed events. CMS expects observed events to be part of the e-notifications and one of the underlying expectations of the Conditions of Participation. This is a current gap for many hospitals today, as they are not necessarily sending this information. Hospitals are required to include this information in the appropriate alerts.
  2. Scope of Coverage: There is a misconception that health information exchanges cannot support hospitals in complying with the CoP, but this is not true. HIEs need to support the ability to send patient directed alerts to non-participants, and HIEs cannot limit patient directed alerts based on geography. In a December webinar, CMS was very clear that hospitals must send a patient’s information to where they direct it to go, using reasonable effort.
  3. Treating Provider: CMS does not provide a clear definition of a treating provider under the Conditions of Participation. There are multiple options to consider for the treating provider: attending, admitting, consulting, and referring. A treating provider is not always assigned or known at the time a notification must be generated.
  4. CMS Audits: Audits are a critical piece in proving compliance with the requirements. While CMS has not detailed what information will be needed to prove compliance, Audacious Inquiry has identified several pieces of information that will be useful for hospitals in generating these reports. For example, one key metric that will prove compliance is a clear record of every emergency room registration event, every emergency room discharge event, every inpatient admission, inpatient discharge, and the percentage of those events for which an alert was generated. Additionally, Audacious Inquiry anticipates CMS will consider the method of alert as well as how often alerts were sent at the request of the patient in its audits.

Admission, Discharge, Transfer Notifications; CMS Compliance; Hospital and Provider Guidance: Looking to Learn More?

From fast facts to reliable resources penned by policy experts, be sure to check out our Conditions of Participation and Encounter Notification Service® information pages.

Craig Behm, Maryland Executive Director, CRISP - "I can be very confident that our members will meet Conditions of Participation Compliance because our partners at Audacious Inquiry are experts in the field."

Bryan Metzger, Sr Vice President – Information Services for the Tennessee Hospital Association said, “Audacious Inquiry’s team has both the level of expertise in policy through their work with ONC and CMS, and the ability to deliver their technical solutions in a rapid, secure, and scalable way. With Ai as a partner, THA’s members are set up for success to meet CMS’ new CoP regulation.”

Bill Wylie, Sr. Vice President – Business Operations for the Georgia Hospital Association expressed, “Ai has been a tremendous partner in finding ways to support GA Notify, but also GHA’s overall data program and data strategy. CoP compliance is just another example of this.”