Addition of Sites to an Existing Provider

3224 - Addition of Sites to an Existing Provider (Rev. 1, 05-21-04) It is inherent in the provider certification process that a provider give notification to CMS of its proposal to expand its service area by adding a branch, satellite or extension location. The Medicare statute and applicable regulations are implicit that the proposed expanded service area meet the Conditions of Participation the same as the primary location that has signed the provider agreement or that has been assigned a provider number or both. In the absence of notification, CMS has no way of determining whether the requirements critical to health and safety are met at the expanded location. For example, a hospice’s request for satellite location may be denied because it cannot demonstrate how the hospice will assume administrative and supervisory responsibility for the services provided at the expansion site. Moreover, there is no basis for a provider to bill Medicare for services provided by a site which has not been determined to meet applicable requirements of participation. When an expansion request is received, before making a determination the RO considers the following: • Whether the proposal meets Medicare statutory and regulatory requirements. For example, in the case of an HHA, does the proposed branch meet the definition of a branch office at 42 CFR 484.2. If it is possible to make a decision based on the provider’s description of how it intends to operate, an onsite survey may not be necessary. • If the proposal complies with State and local laws related to the particular type of provider/supplier; and • Whether Medicare reimbursement is affected by the proposal. For example, a hospital states that is has purchased a physicians’ clinic that is now a part of the hospital. In such a case, input from the Division of Medicare and the fiscal intermediary will likely be necessary. While CMS does not dictate to a provider how it should operate its business, the provider does have to comply with Medicare requirements. Whenever an entity can meet the requirements of two different categories; e.g., subunit and independent home health agency, it is generally CMS’ policy to designate the category for which there is the least potential to increase Medicare costs. If a proposed branch is in an area that would receive a different payment rate than the parent HHA, it could be found to be in a different geographic area and determined not to be a branch. Although legal authority exists for conducting a survey, a survey may not be necessary because the provider furnishes the RO with sufficient information to make a determination about its proposed expansion either at the time of its initial request or subsequently. If the RO believes a survey is required, but the SA is unable to conduct a survey within a reasonable period of time, the RO may take one of the following actions: • Make a determination based on the expansion information provided by the provider and inform the provider of the decision; and • Inform the provider that a survey will be necessary and that it should not bill Medicare for services provided at the proposed expansion location until the survey is conducted and a determination is made. In the absence of notification of an expansion, CMS has the authority to deny bills for services furnished at the expanded site. When notification is received of a proposed expansion, the RO should inform the provider of whether the expanded site meets applicable requirements. The fiscal intermediary should be notified of the RO’s decision. Validation Surveys of Accredited Providers and Suppliers