Factors that may be used to determine if hospital requirements apply

The difference between being accredited as a hospital or as an outpatient center can mean a difference of thousands of dollars in revenue when billing Medicare. And if you are a smaller, specialty hospital or an outlying facility that is part of a larger health system, be prepared: CMS and other surveyors will expect proof that you meet the requirements for being surveyed as a hospital and not as some other type of provider.

While CMS survey-and-certification memo 17-44-Hospitals notes that surveyors will start with the average daily census (ADC) and average length of stay, it notes the following as other factors that the CMS regional office may consider when determining whether to conduct a second survey or recommend denial of an initial applicant or termination of a current provider agreement. According to a newly revised survey-and-certification memo from CMS clarifying how the federal agency defines a hospital, these factors include but are not limited to:

• The number of provider-based off-campus emergency departments (ED). An unusually large number of off-campus EDs may suggest that a facility is primarily engaged in providing outpatient emergency services, rather than inpatient care.
• The number of inpatient beds in relation to the size of the facility and services offered.
• The volume of outpatient surgical procedures compared to inpatient surgical procedures.
• If the facility considers itself to be a “surgical” hospital, are procedures mostly outpatient?
• Does the information indicate that surgeries are routinely scheduled early in the week, and does it appear this admission pattern results in all or most patients being discharged prior to the weekend (for example, does the facility routinely operate in a manner such that its designated “inpatient beds” are not in use on weekends)?
• Patterns and trends in the ADC by the day of the week. For example, does the ADC consistently drop to zero on Saturdays and Sundays? If so, this suggests the facility is not consistently and primarily engaged in providing care to inpatients.
• Staffing patterns. A review of staffing schedules should demonstrate that nurses, pharmacists, physicians, etc. are scheduled to work to support 24/7 inpatient care versus staffing patterns for the support of outpatient operations.
• How does the facility advertise itself to the community? Is it advertised as a “specialty” hospital or “emergency” hospital? Does the name of the facility include terms like “clinic” or “center” as opposed to “hospital”?