FOR THE SAKE OF ARGUMENT, let's say you're one of the good guys.

You're not one of the scam artists who have given the home medical equipment industry a bad name. You're not responsible for the congressional pit bulls that h ave been turned loose on fraudulent providers and, in the process, have wreaked havoc on you and your peers. It's disgusting that you have to pay some accrediting commission to prove it, but fighting city hall is not what you'd call "cost-effective" either.

So, as a card-carrying Medicare provider who not only complies with the old supplier standards but also with the proposed new set about to take effect, you've decided to become-deep breath-accredited.

Now what?

Remember, accreditation is voluntary. It's also what you could call a necessary evil. It's burdensome and expensive, twin evils. But an increasing number of providers believe it necessary anyway because the bottom line for HME providers today is legitimacy.

And until somebody comes up with a better idea-be it licensure or some derivative-accreditation is the most widely accepted declaration of legitimacy, not to mention a prerequisite for most managed care contracts.

So, if you've never been accredited, you're probably wondering what it's like.

"It's a horrible experience," says Jeff Wills, who went through it in March as the chief operating officer of Canadian Valley Medical Solutions, El Reno, Okla. "You feel like a wet dish rag when you're done. But businesswise, it's a great learning experience. It was the right thing for us to do."

Wills' company was accredited by the Joint Commission on Accreditation of Healthcare Organizations, whose home care program was established in 1988 to assess and improve the quality of provider services. It is generally considered by many insurers and case managers to be the industry benchmark. JCAHO evaluates all health care services provided by an organization against applicable standards and makes an accreditation decision and survey report. A JCAHO accreditation is good for three years.

But JCAHO isn't the only accreditation agency. The Community Health Accreditation Program has accredited home care organizations since 1965. In 1987, it became a subsidiary of the National League of Nursing Inc. CHAP's stated purpose is to ensure that providers adhere to the highest standards of excellence, while assuring confidence in consumers. A CHAP accreditation is good for three years.

The Accreditation Commission for Home Care was established in Raleigh, N.C., in 1986 and expanded nationwide 10 years later. It boasts an accreditation program developed by providers for providers. The person conducting the survey will have five years of HME management experience and background in quality assurance or accreditation. An ACHC accreditation is good for three years.

No matter which agency you work with, the linchpin to each accreditation process is the site survey, which can last from a day to several weeks, depending on the size of the organization and the services offered.

How much does it cost? Well, as an example, JCAHO survey fees are complex and vary according to the number of patients serviced, the number of sites and contracts involved, and the number and type of services, officials say. JCAHO will estimate a fee upon request, but the minimum accreditation fee, officials say, is $2,750. Factoring in staff wages and consulting fees for preparation, the total cost can easily exceed $25,000 for the initial accreditation.

Is it worth it?

Well, consider the accreditation process as being similar to taking a test. Do you study just to pass the test-or to learn the subject matter?

"You're not doing it just for the gold seal," says Bob Thornburg, a Seal Beach, Calif.-based consultant and former surveyor who has worked with 450 companies on their surveys. "You need this to put in place policies and procedures to prepare for the future of your business. It applies to everything your business does."

Which means that the surveyor must have a solid understanding of the HME business. In the case of an HME accreditation by JCAHO, the surveyor has either owned or managed an HME business for at least three years or has had equivalent administrative experience in a large company and has worked in the home care field for at least five years. JCAHO uses more than 700 surveyors to conduct roughly 10,000 surveys annually, officials say.

The surveyor has a working knowledge of the use and maintenance of the equipment the organization provides: If clinical respiratory services are provided, a registered respiratory therapist will be assigned.

Providers must demonstrate in the survey how they serve their patients and protect their employees in terms of safety, so preparation is essential. Companies already accredited should start the process 14 months before the survey, accreditation experts say, because a one-year track record of compliance to standards is required. A new organization needs a four-month track record, so preparation should begin roughly one year in advance.

"It is the most massive undertaking a business will ever experience," says Thornburg.

Pinpointing areas of noncompliance in advance of the survey, and improving those results, can be decisive in accreditation. If many areas are not in compliance, a priority action plan should be developed to correct problems. Among the areas most frequently problematic, experts say, are performance improvement, competency evaluation of care staff and care planning.

An often overlooked preparation involves a company's staff and its understanding of the importance of standards. JCAHO officials stress that providers are responsible for an organization-wide approach to the standards, not just as they pertain to specific departments. Because staff interviews are part of the survey process, what could help, experts say, is conducting a mock survey to review the improvement of services and address problem areas before the actual survey. Some organizations hire consultants to conduct them. In addition, seminars are offered by JCAHO and professional organizations; and networking with providers who have recently completed the survey can also be a help.

Just prior to the survey, providers should meet with staff to review expectations and relieve anxiety. In recent years, standards have become patient-centered, performance-focused and organized around functions common to all health care organizations. The survey focuses on those functions.

THE JCAHO WAY JCAHO evaluates an organization's performance by using standards, or in its simplest terms, expectations. Performance is measured in terms of outcomes, or results. The framework is divided into functions that are either patient-focused or organization-focused.

Patient functions consist of rights, responsibilities and ethics; assessment; care, treatment and service; education; and continuum of care. Organization functions consist of improving performance; leadership; managing environment of care; managing human resources; managing information; surveillance; and prevention and control of infection.

Compliance grading is done on a 1-to-5 scale, with 1 "always compliant," 2 "usually," 3 "sometimes," 4 "rarely" and 5 "never."

The jackpot at the end of the accreditation rainbow is "deemed status." JCAHO defines this as "status conferred by the Health Care Financing Administration on a health care provider when that provider is judged or determined to be in compliance with relevant Medicare conditions of participation because it is accredited by a voluntary organization whose standards and survey process are determined by HCFA to be equivalent to those of the Medicare program."

Accreditation cannot be transferred to new owners of an organization. Upon notification of ownership change, accreditation will be continued by JCAHO until it determines whether a special survey is necessary.

THE CHAP SURVEY METHOD There are four steps to a CHAP survey: application, self-study, site visit and board of review findings. CHAP differs from JCAHO in that consumers, as well as representatives of business and insurers, sit on the boards of directors and review. Also, CHAP makes its decisions public.

Annual fees are based on a sliding scale according to an organization's gross revenues. An initial, non-refundable application fee of $3,150 for an organization with revenues of $1.5 million or less is required at the time of application and is deducted from the first annual fee.

An additional per diem charge of $950 is levied to cover site visit expenses and HME surveys are for three days, but CHAP finance coordinator Fabian Fraser says CHAP does not add charges based on multiple locations, as JCAHO does. Site visits are unannounced and typically take four days to complete.

THE ACHC SURVEY METHOD Similar to the other two accreditation commissions, ACHC's site survey includes a review of personnel files, client records, budgetary information, policies and procedures, quality improvement plan, and operational and service delivery outcomes. Scoring is done on a 0 to100 grid, with a minimum of 85 percent for each section and service required for a three-year accreditation.

The base fee for ACHC accreditation is $2,500, but total costs increase depending upon the number and types of services provided, number of locations and volume of patients. There is an additional survey fee of $750 for the first day and $500 each additional day per surveyor, plus expenses.