‘Yellow Light’ Measures to Help You Prepare for A Medicare Survey


How to prepare for recertification

By Heidi Rose Bender, MBA

Nothing gives one pause or caution like the thought of an impending Medicare survey. As a rehabilitation agency, you know that every five to six years you are subject to an onsite unannounced Medicare recertification survey.

If you have multiple sites, typically Medicare will choose only one site to survey. However, as I learned from MRS Physical Therapy’s last survey, Medicare may choose to survey multiple sites on the same day at the same exact time. On that particular day, a department of health surveyor showed up at the clinic where I work and as I was actively providing her the information she requested, I received a call that a surveyor was also at one of our extension site locations. Talk about a moment of pause!

So how can you be sure you are prepared and that you have taken all necessary precautions to ensure full compliance with the requirements of 42 CFR, Part 485.727, Subpart H, Conditions of Participation for Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services – Emergency Preparedness? Slow down and prepare, prepare, prepare!

The first step is your Medicare manual. Your Medicare manual is your guide to all things Medicare in your clinic. Your manual is a living and breathing document that must be updated on a continual basis.

Your manual should be easy to access by your clinicians and your front office staff. The answers to most questions a Medicare surveyor will likely ask should be found in your Medicare manual.

When a surveyor asks these questions, they will typically want to see three years’ worth of documentation. So that means three years’ worth of stats, chart audits, employee reviews, disaster drills, meeting minutes, and compliance education. Where better to hold a majority of this information than your Medicare manual? If you have multiple locations, I recommend each location has an electronic manual that is accessible to both staff on-site as well as corporate staff. This means that corporate staff can audit extension site manuals to ensure they are being kept up to date. Also, in order to promote staff familiarity with the Medicare manual, it is a good idea to assign all employees tasks associated with the manual. For example, at MRS, front office staff typically update the clinic communication matrix and upload staff meeting minutes. Facility directors are in charge of coordinating disaster and fire drills.

The next step is to ensure mock surveys are being performed at each rehabilitation agency site on a quarterly basis. Each manager or director should survey as if an actual Medicare survey is being conducted. A uniform mock survey template should be used to ensure surveys are consistent and encompass all Medicare guidelines.

Once you have completed step one by developing a Medicare manual that is solid and up to date and your clinic or clinics are mock surveyed on a regular basis, you have taken meaningful precautionary or “yellow light” measures to guide your practice through the green light of a successful Medicare survey. Now that doesn’t mean you won’t be thrown the occasional curve ball such as two surveyors showing up at the exact same time at two different locations. One of the inspectors told one of our clinicians that they deliberately inspected at the same time to make sure that there was not just one person in our company that was familiar with Medicare Rehabilitation agency requirements. They wanted to make sure that our company as a whole was guided by rehab agency requirements. Their goal was to challenge our organization and we successfully met that challenge with zero deficiencies thanks to all the yellow light measures we put in place prior to survey.

Heidi Rose Bender, MBA

Heidi Rose Bender, MBA, is the VP of operations for MRS Physical Therapy, LP. She has worked in the field of physical therapy since graduating from Gannon University with a Master of Business Administration.

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