The HHS rules currently provide that, under The Conditions of Medicare Coverage, CSA maintains either a written transfer agreement with a "participating Hospital in Medicare, or a non-participating local hospital meeting the conditions for payment of emergency services", or ensure that any physician who provides services to the CSA has initiation privileges in such a hospital. Under the final rule, CSAs are no longer specifically required to maintain a formal hospital transfer contract or to ensure that their physicians retain the privileges of admission to a particular hospital. Instead of the written transmission agreement, the final rule generally requires CSAs to maintain an effective procedure for transferring patients who require emergency treatment to the hospital. "For too long, the local hospital system has used such tactics only to stifle or restrict competition, which keeps health care prices largely artificially high and reduces consumer choice in the health sector," Tippets said. While 43 states require CET accreditation, only 30 require the ability to obtain emergency outpatient care. Fifteen of them are asking for a hospital transfer contract. The others require either an agreement or a hospital that grants privileges to CSA surgeons. (See the "State Situations" sidebar.) Hospital industry leaders are urging the CMS to abandon a proposal that would make the need for a written transfer agreement redundant when an outpatient operations centre attempts to transfer a patient to the hospital. Transfer agreements must clearly define the respective responsibilities of the CSA and the hospital in a number of areas, including the transmission of patient information; Providing transportation; Sharing services, equipment and staff Providing care for agency setting and capacity; and the confidentiality of patient records.

The active conditions of a hospital visit vary from case to case and must be defined in the written document. A transfer agreement may have an expiry date or it may indicate that it will remain in effect until a party terminates the contract. "The transfer contract is essentially the emergency planning document," Litka-Klein said in the letter. As part of the agreement, hospitals and operating centres outline typical procedures and common care protocols, Litka-Klein wrote. All CSAs that treat Medicare receptors must be certified by the Medicare program and, therefore, meet the federal CSA requirements. One of these requirements requires the CSA to have a written transfer agreement with a local hospital participating in Medicare or a non-participating hospital that meets the Emergency Services Requirements of the Medicare program. If the CSA does not have a transfer contract, any physician operating in the CSA must have admission privileges to a particular CMS-compliant hospital. Florida deals with the subject from the point of view of medical qualifications. If a physician is not allowed to perform his ASC procedures in a hospital at a reasonable distance, a transfer contract must be concluded in advance.

And Georgia notes that hospitals "will not unduly reject a transfer agreement to the CSA." 1. CSA must not have a written transfer contract or hospital planning privileges for all physicians. Centres must provide hospitals with a document containing information about their surgery and patient population.

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