CMS 2007

September 24, 2007

Kerry N. Weems
Administrator
Centers for Medicare & Medicaid Services
200 Independence Avenue S.W. Mail Stop 314G
Washington, D.C. 20201

Thomas E. Hamilton
Director, Survey & Certification Group
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-12-25
Baltimore, Maryland 21244-1850

Re: Medicare Initial Certification Surveys

Dear Sirs:

On behalf of the Texas Hospital Association I am writing to express concerns about the substantial delays Texas hospitals are experiencing in the scheduling of Medicare initial surveys. Such delays are creating serious financial and operational challenges for those hospitals that have been appropriately licensed by the Texas Department of State Health Services and expected to have a Medicare survey conducted within a reasonable period of time after the state license was issued. In a fast growing state like Texas, these delays in the survey process also may adversely impact access to care by Medicare beneficiaries.¹

There are approximately 17 or more Texas hospitals that have been notified by the TDSHS that initial surveys cannot be scheduled due to budget constraints within the survey and certification program and that it is uncertain when these surveys will be conducted. It is anticipated that additional hospital requests for initial surveys will be made in the coming months. Thus, it is critical for your agency to commit adequate resources to the survey process so that the delays we are facing in Texas do not become much worse.

From our review of various memoranda issued by the Survey and Certification Group, it is our understanding that the state survey agencies have been directed to consider initial surveys for all provider types, with the exception of ESRD service providers, as the lowest priority (Tier IV). Further, the state agencies are not authorized to conduct the Tier IV surveys until all higher tier work has been conducted. While we understand the need to establish priorities, we would encourage CMS to reassess its prioritization of surveys. For example, states are currently required to perform validation surveys for at least one percent of the accredited hospitals within the state. In Texas, this policy results in the TDSHS dedicating a significant amount of its funding to validation surveys. As a consequence, the agency has not had sufficient resources available to conduct initial surveys in a timely manner. We believe that the policy should be changed and validation surveys should be moved to a much lower priority.

In addition, we believe that the CMS survey priority policy must be modified for those hospitals that do not have the option to apply for deemed status through an approved accreditation agency. As you know, all new rehabilitation and psychiatric hospitals or units that are reimbursed as an excluded unit must meet additional regulatory standards² and do not have deemed status as an option. A higher priority level should be established for these rehabilitation and psychiatric hospitals and for others that do not have deemed status as an option due to their financial situation or other special circumstances.

Beyond any changes in survey process policies, we believe that it is essential that the state agencies receive adequate funding so that all required surveys are conducted within a reasonable period of time. As you will note, the Texas congressional delegation is receiving a copy of this correspondence and our association has encouraged our Texas elected officials to consider this issue carefully and support the appropriation of additional funds to the Medicare survey and certification program. We trust that this appropriation will be made for fiscal year 2008 and that CMS will make appropriate allocations of the additional funding to the survey process.

Your prompt attention to this matter would be appreciated. If you have questions about the situation in Texas or the recommendations made to modify the survey policies, please feel free to contact me at 512/465-1012.

Sincerely,

Dan Stultz, M.D., FACP, FACHE
President/CEO

cc:
The Honorable Kay Bailey Hutchison
The Honorable John Cornyn
The Honorable Joe Barton
The Honorable Kevin Brady
The Honorable Michael Burgess
The Honorable John Carter
The Honorable Michael Conaway
The Honorable Henry Cuellar
The Honorable John Culberson
The Honorable Lloyd Doggett
The Honorable Chet Edwards
The Honorable Louie Gohmert
The Honorable Charles Gonzalez
The Honorable Kay Granger
The Honorable Al Green
The Honorable Gene Green
The Honorable Ralph Hall
The Honorable Jeb Hensarling
The Honorable Ruben Hinojosa
The Honorable Eddie Bernice Johnson
The Honorable Sam Johnson
The Honorable Nick Lampson
The Honorable Sheila Jackson Lee
The Honorable Kenny Marchant
The Honorable Michael McCaul
The Honorable Randy Neugebauer
The Honorable Solomon Ortiz
The Honorable Ron Paul
The Honorable Ted Poe
The Honorable Silvestre Reyes
The Honorable Ciro Rodriguez
The Honorable Pete Sessions
The Honorable Lamar Smith
The Honorable Mac Thornberry
The Honorable Jane Nelson
The Honorable Dianne White Delisi
Molly Crawshaw, Centers for Medicare & Medicaid Services
Kathryn Perkins, Texas Department of State Health Services

¹ According to the U.S. Census Bureau, Texas has moved from sixth to third in the country for the number of senior citizens in the last ten years and Texas’ senior population is projected to grow by 800,00 by 2015.

² A PPS excluded rehabilitation unit is regulated by both the hospitals conditions of participation, 42 CFR §482, and rehabilitation unit requirements at 42 CFR §§412.25 and 412.29; a PPS excluded psychiatric unit is regulated by both the hospitals conditions of participation, 42 CFR §482, and psychiatric unit requirements at 42 CFR §§412.25 and 412.27.