The April 15th Deadline Has Passed – Now What?

Many of you have probably looked at the date that we have referenced in the title of this article and are wondering why we are referencing the last day to file your taxes. For healthcare organizations, April 15, 2024 has a different significance this year, especially if your organization uses an accrediting organization to achieve Deemed Status with CMS.

A little bit of history:

Earlier this year, the Centers for Medicare, and Medicaid Services (CMS) published a proposed rule that has the potential to affect the 9,000 accredited health care providers that undergo a CMS- approved program survey through an approved accreditation organization (AO). The proposed rule continues the journey and goal that was begun by Congress prior to the pandemic to strengthen their obligation and sustain public trust in our healthcare system by providing greater oversight to the CMS approval process.

Annually, CMS is obligated to provide a report to Congress that summarizes the overall performance of our health care system and the performance of the Accrediting Organizations approved to evaluate the individual performance of the health care providers seeking reimbursement through the CMS sponsored programs. For years, the report has included data related to the disparity rate between deficiencies found during accrediting organization surveys and CMS validation surveys. In more recent years, CMS has expressed concerns related to the sustainment of Accreditation in organizations that have been placed on Termination track by CMS, the provision of advanced notification of survey dates that allow organizations to “ramp up” for the survey event, and most recently, concerns related to the potential conflict of interest created by the provision of fee-based consulting services being provided to those to which the Accrediting Organization performs CMS deemed status surveys.

What the rule includes:

To continue to enhance its public-trust mission, CMS proposed the following rules which were published in the Federal Register on February 8, 2024:

  • The establishment of expectations and processes to hold Accrediting Organizations to the same standards as State Survey Agencies.
  • Creating the limitations and barriers needed to ensure that the Accrediting Organizations remain independent reviewers by addressing conflicts of interest and placing limitations on the provision of fee-based consulting services to the HealthCare Organizations they accredit.
  • Building a robust conflict of interest process that prohibits Accrediting Organization employees with potential conflicts due to relationships with healthcare organizations from being engaged in the pre-intra and post survey work at the Accrediting Organization level.
  • Establishing a process whereby key information would need to be reported to CMS related to how they would implement a prevention and monitoring process to ensure conflicts of interest are intercepted.
  • Creating a mechanism where poor performing Accrediting Organizations would need to submit a written plan of correction that would be available to the public.
  • Creating a more consistent interpretation of the standards and more consistent survey process that aligns the individual accrediting organization processes to those of CMS.

The above proposed rule addresses CMS’ goal of strengthening oversight, increasing transparency, ensuring health and safety, enhancing enforcement which will ultimately lead to higher quality safer care across our health care system.

The initial proposed rule was published on February 8th and the public comment period closed on April 15th, along with the due date for most people’s tax returns to be filed.

Next Steps:

We expect that many comments were submitted from both accrediting organizations, health care organizations, health care providers and patient safety organizations, and that CMS will have volumes of comments to review and reply to. We will keep our eyes focused on any updates to the rule and share with you in future articles.

For questions or to learn more contact the C&A team at 704-573-4535 or email us at

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