The FACS on Accreditation

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What to look for in an Accreditation Organization and why it matters — from a provider’s perspective

TCT’s provider participants:

  • Steve Ackerman, founder and CEO of Spectrum Medical, Inc, a DMEPOS company based in Silver Spring, Maryland
  • Trish White, co-owner of Harry Race/Whites Pharmacy and Home Medical Equipment, Sitka, Alaska (located on Baranof Island, in the southeast portion of Alaska)
  • Wade Hendrickson, owner, Physician’s Choice Medical, LLC, Denver, Colorado – 3 DMEPOS locations
  • Melynda Breeze, co-owner of Byrd-Watson Medical Downtown, a DMEPOS business located in Mt. Vernon, Illinois

History. Prior to 2006, before the Centers for Medicare and Medicaid Services (CMS) mandated accreditation for suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), there was no consistency on accreditation guidelines or daily processes and procedures. Fraud, waste, and abuse were rampant. After the introduction of the Medicare Modernization Act, CMS required that all DMEPOS companies be accredited to qualify for reimbursement. CMS released its standards and deemed 10 accreditation organizations to accredit DMEPOS suppliers.

Why Accreditation? Accreditation by a CMS-deemed accreditation organization (AO) verifies and validates that your facility meets/exceeds the CMS minimum requirements. However, the value of accreditation extends well beyond CMS reimbursement. Accreditation refines processes and procedures that take your business to the next level of care.

“Even if it wasn’t a Medicare requirement, I would still choose to go through the accreditation process,” Steve Ackerman said. “Accreditation helps make us a better company, from employee retention to equipment management to infection control. When the provider feels like he can come on board in a ‘civil way,’ his accreditor becomes a friend for life.”

Trish White noted that “accreditation teaches valuable organizational processes – things you don’t learn in pharmacy school. As an accredited entity, everything must be documented. If you didn’t document it, you didn’t do it.” In fact, White’s Pharmacy was so impressed with what it learned from DMEPOS accreditation, Trish signed up for the Community Pharmacy accreditation program a few years later. As a pharmacy owner, Trish said she appreciates what accreditation has done for the business. “Every time we get a pharmacy benefits manager asking for re-credentialling, it is very easy. We have all our documentation in one place. Accreditation has made administration a lot cleaner, a lot easier to do.”

Improved processes and services lead to improved patient outcomes. Accreditation proves to your payors, your patients, your clients, and your staff that you are committed to continuous quality improvement. It brings value to your patients and your business by identifying procedural gaps and recognizing opportunities for improvement.

Finding an accreditation organization that meets your needs can be daunting, especially if you are new to the DME industry. Over the years, The Compliance Team™ (TCT) has heard comments from many of its customers as to what they feel is most important in the accreditation process. TCT condensed that feedback into what it calls the FACS – Flexibility, Accessibility, Consistency, and Simplification. TCT considers these qualities to be the minimum requirements you should consider when evaluating a potential AO.

Why The FACS Matter

Be sure to look for an AO that reviews and updates the standards on a regular basis, so you can be current with CMS changes and market dynamics. You also want an AO that can respond to your business issues and questions quickly. The “one size fits all” mentality was not popular with any of the providers interviewed. You will want an AO that will match the standards to an individual provider organization’s business model, not the other way around. This saves you time, not only during the accreditation process but also later, when you are training your personnel on new or revised processes.

As the owner of a small business, Steve said he also appreciates when the AO can be flexible with its payment plan.

Wade Hendrickson said he likes that the AO can accredit “a variety of disciplines and is willing to cater to a range of business sizes.”

Whether you are new to accreditation or renewing, you need answers as quickly as possible to keep the process moving forward. When evaluating AOs, be sure to find out what they include in the accreditation process and what is fee-based. Ask about one-on-one support as well as the availability of support tools. Each of the interviewed providers stressed how important it is to get answers to questions when they need them.

Melynda Breeze confirmed that “having information at our fingertips is most important.” She uses the AO’s checklists, webinars, and phone calls when preparing for accreditation renewal.
Trish said she appreciates an accreditor that understands the challenges of her business and helps her work around them.

“When you are dealing with friendly, knowledgeable people who understand your business, you attain a certain comfort level that lets you get the most out of the accreditation program,” Wade noted.

Consistency means ensuring that your advisors and surveyors are consistent with their messaging. Steve, who has worked with multiple AOs over the years, said he appreciates when surveyors are professionals who can help improve processes and are not clinicians with white gloves looking for problems. “There is a delicate balance between staying on top of issues and making you accountable without calling you out on things,” Steve said. He also welcomes the accreditation experience because “when they leave, we always have something that has been improved.”

Wade confirmed the consistency of messaging. “There should be fresh ideas, but the guidelines must be consistent, no matter who is doing the on-site visit.”

Your advisor/surveyor will do a physical on-site visit every three years. Be sure that your AO is either using its own staff members or hiring contractors who are trained and familiar with the standards and with your business model. You will want to work with an accreditor that employs advisors who have extensive knowledge of your industry, so they can not only quickly recognize deficiencies but can offer recommendations for doing things better or more efficiently.
Melynda affirmed that “checklists and dependable processes from our AO help keep us consistent with our own processes so that our patients and employees are safe.”

The accreditation standards should be comprehensive, yet simple enough for any of your employees to understand. This makes it easier for you to attain and retain your accreditation status.

After years of working with AOs, Steve said he wants accreditation to make sense and be easy to follow. He also commented on using regular quality assurance meetings to help with problems as well as opportunities. When he and his staff are meeting regularly, they find new ways to streamline processes and ensure deficiencies aren’t creeping into the core of the business. His team also discusses opportunities for strategic growth.
Wade explained that, through the accreditation process, his accreditor found a way to make some of his processes simpler. He also values the “practicality” of the standards, which should be “stringent where they have to be, and flexible when they can be.”

“The simplified checklists and standards help keep my business processes running smoothly, especially in dealing with the challenges we faced during the pandemic,” Melynda said. “Regular webinars help prepare us for changes in the industry.”

For some, accreditation means direct, monetary reimbursement. However, for any business that invests in an accreditation program, accreditation becomes a long-term business investment. Wade states it clearly: “You must look at the cost of accreditation as a cost of doing business. If you accept it instead of fighting it, you will improve the strength of your business. Accreditation forces you to do the things you know you should do and plan to do but never get done.”
Trish, whose children are now pharmacists getting involved in the business, summarizes accreditation benefits this way: “We have seen from our children that, for young people, quality assurance and quality assessment come naturally. It is a natural path to start with

policies and procedures, create your business plan, make sure you can prove to anybody that you are on the right path, that your business is sustainable, and that you are making money at it. . . Continuing to step up our services is what will keep us sustainable and relevant.”

The Compliance Team
The Compliance Team is a nationally recognized healthcare accreditation organization (AO). Its industry-leading accreditation model features healthcare’s first comprehensive set of plain language, operations-driven quality standards with expert-led implementation guidance. TCT has the distinction of being the first woman-owned AO to be approved by the Centers for Medicare & Medicaid Services to accredit Part-A Rural Health Clinic and Patient-Centered Medical Home and Part-B DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, Supplies) and Home Infusion Therapy (HIT) providers. Its proprietary accreditation and certification status, known as Exemplary Provider®, is also offered for Pharmacy Services (including Community Pharmacy + Medicare approved DMEPOS, Long-Term Care, Specialty Drug, Compounding, Infusion, TelePharmacy, Patient-Centered Pharmacy Home™, and Clinical Disease Management™), and Immediate Care Clinic. Its latest certification programs on Immunization and POC testing can be utilized in pharmacies and public health settings.

What makes The Compliance Team unique?
Included with each accreditation and certification program:

  • An assigned advisor who mentors you through a virtual review of the Quality Standards and Evidence of Compliance
  • A series of one-on-one web-based calls to guide you through preparation for the on-site visit
  • Self-assessment checklists that keep you on track
  • Access to live and recorded webinars to help you through the accreditation process and understand key topics
  • Policy and procedure templates that are designed to help you customize your policies to meet your scope of practice and business model
  • Real-time help during standard business hours and accreditation advisors who are on call via email
  • Flexible payment schedule for no additional fee

The Compliance Team continues to monitor the industry and address issues that may be of value to DMEPOS and pharmacy providers.

For more information about The Compliance Team’s programs, visit or call 215-654-9110.

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