New CMS process for equivalencies requires hardship assessment


June 5, 2015

Many ASHE members are receiving rejection notices on equivalencies because of a revamped process for submitting and approving equivalencies. The issue affects both traditional equivalencies and Fire Safety Evaluation System (FSES) submissions. This ASHE issue brief explains the issue and provides members with guidance on how to resubmit equivalency requests with the information needed for approval.

In July 2014, the Centers for Medicare & Medicaid Services (CMS) made a policy change that requires CMS regional offices to approve or deny equivalencies. Previously, this work was done by accreditation organizations such as the Joint Commission. Under the new process, facilities submit equivalencies to accreditation organizations, which in turn submit them to CMS for a decision.

Hospitals are seeing the effects of announcements last year in which CMS said it was changing the process for equivalencies. The change in process, initiated last July, required a third party review of hundreds of pending equivalencies and FSES submissions. After developing and implementing the process, hospitals are just now receiving their determinations.

CMS requires that any request for deviation from adopted codes should include an assessment of hardship that explains the need for the deviation, as well as assurance that overall patient safety will not be diminished by the equivalency. Although an equivalency is technically considered compliance with the code, CMS still requires the hardship assessment and statement regarding patient safety.

According to CMS, an unreasonable hardship could include factors such as costs, the extent and duration of disruptions of patient areas, the availability of financing, and the remaining lifespan of the building.

ASHE members who submitted equivalencies without hardship assessments are receiving rejections. ASHE recommends that members follow instructions provided by their accreditation organizations and include the statement of hardship before electronically resubmitting the equivalency.

For members preparing equivalency submissions in the future, keep in mind these requirements. For more information on preparing FSES equivalencies by clicking here.

Key Points

The Centers for Medicare & Medicaid Services (CMS) regional offices now determine whether equivalencies are approved (a task previously completed by accrediting organizations).

CMS requires that any deviation from the adopted codes include an assessment of hardship and assurance that patient safety is not diminished.

Facilities that have had equivalencies rejected should include a hardship assessment and statement on patient safety and resubmit.

ASHE staff contact:
ASHE Deputy Executive Director of Advocacy
Chad Beebe, AIA, SASHE