12/17/2015

Medical Board and Accrediting Agencies Outline New ASC Requirements

CASA Member 805 Tool Kit

As reported last September, Governor Brown signed SB 396 (Hill) into law.  This legislation addresses California accredited outpatient settings and provides consumer protection enhancements.   CASA has been working with the Medical Board of California (MBC) and the MBC approved Accrediting Agencies (AAs) on their interpretation and application of these changes.  The MBC has released a guidance letter to the AAs outlining expectations for ASCs beginning January 1, 2016.  This letter is included in the following link and we encourage all ASCs to read thoroughly to assure they are meeting all the requirements.   All California Accredited Outpatient Settings Letter Summary

The legislation focuses on three areas:

Unannounced Inspections –Allows the AA to conduct unannounced inspections after the initial inspection for accreditation.  The new law does not require unannounced inspections, but does allow an AA to conduct unannounced inspections if it so chooses.  ASCs should communicate with their individual AAs on their protocol.

Peer Review Evaluation- Requires that peer review be performed at least every two years and include the provider’s basic qualifications, staff privileges, employment, medical outcomes, and professional conduct.  It is important to note that some AAs may require more frequent peer review.  We encourage all ASCs to assure their bylaws, policies and protocols meet the requirements as outlined in the letter and their individual AA.  The MBC does clearly outline that the credentialing process is separate from the peer review process, and ASCs that credential every three years may continue to do so.

805 Reports –Applies to, not only accredited outpatient settings, but to all ASCs certified to participate in the federal Medicare Program.  As of January 1, 2016, ASCs prior to granting or renewing staff privileges need to access the Board's License Verification System (LVS), to determine if an 805 report has been filed indicating that the physician and surgeon, psychologist, podiatrist or dentist has been denied staff privileges, been removed from a medical staff or had his or her staff privileges restricted.  All ASCs will need to subscribe to the LVS.  CASA has worked with the MBC to develop a step by step document that will assist our CASA members with this process.  805 Step by Step Tool

Again, ASCs should review the MBC guidance letter and assure that all of their processes and oversight are in line with these new requirements. If you have any questions regarding the requirements ASCs are encouraged to contact their individual AA, the MBC's licensing program at 916.263.2393, or CASA Executive Director Beth LaBouyer at 530.790.7990.