Privileging Telemedicine

Practitioners in Hospitals/CAHs

Jeannie Miller, RN, MPH Deputy Director, Clinical Standards Group

Office of Clinical Standards and Quality

Centers for Medicare & Medicaid Services

March 15, 2012

Disclosure

• This presentation includes discussion of the impact of new

regulations on hospitals & CAHs that demonstrate

compliance with Medicare Conditions of Participation via

accreditation programs offered by one of the 3 CMS-

approved private accreditation organizations (AOs).

– American Osteopathic Association

– DNV Healthcare

– The Joint Commission

• CMS approves applications from any national AO for an

accreditation program that meets or exceeds Medicare

standards in accordance with Section 1865 of the Social

Security Act. CMS exercises continuing oversight over

approved programs.

2

Context

• Hospitals & critical access hospitals

(CAHs) must comply with Medicare

Conditions of Participation (CoPs) in order

to participate in the Medicare program

• Federal Medicaid regulations require

hospitals to satisfy the Medicare CoPs

3

Context

• Separate CoPs for:

– Hospitals (42 CFR Part 482)

– CAHs (42 CFR Part 485, Subpart F)

• CoPs apply to care provided to all patients,

not just Medicare/Medicaid beneficiaries

4

Context

• Hospitals/CAHs have 2 options to

demonstrate compliance with the CoPs,

i.e., assessment by:

– State Survey Agency; or

– CMS-approved accreditation program

• AOA/HFAP

• DNV Healthcare

• The Joint Commission

5

Context

• Accreditation option is voluntary, but can

be a faster means for new facilities to enroll

in Medicare

• 85% of hospitals/30% of CAHs use AO

option

6

Context

• When the CoPs change:

– CMS revises its official guidance on applying

the CoPs, the State Operations Manual; and

– Approved accreditation programs must change

their standards to meet or exceed the revised

CoPs

• CMS must review and approve the revised AO

standards

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Telemedicine Privileging Rules

• CMS proposed revisions to hospital and

CAH regulations governing telemedicine

privileging to:

– Encourage innovation in delivery of patient care

– Increase flexibility, particularly for small, rural

hospitals and CAHs

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Telemedicine Privileging Rules

• New rules aim to increase patient access to care

while reducing duplicative burdens on hospitals

and CAHs.

• Support realizing the potential of telemedicine

while still maintaining essential patient protections.

9

Telemedicine Privileging Rules

• Final rule adopted May 5, 2011 (76 FR

25550)

– Can access at:

http://www.gpo.gov/fdsys/pkg/FR-2011-05-

05/pdf/2011-10875.pdf

• Effective July 5, 2011

10

Telemedicine Guidance

• CMS issued its interpretive guidelines for

the revised CoPs on July 15, 2011

– Can access at:

https://www.cms.gov/Surveycertificationgeninfo/

downloads/SCLetter11_32.pdf

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Key Terminology

• “Telemedicine” vs. “telehealth”

– Industry uses “telehealth” as the broader term

– But Social Security Act defines “telehealth” to

address only what Medicare will pay for –

limited to certain services in rural areas

– CoP changes meant to cover services to all

patients, in both urban and rural settings, so

“telemedicine” is used as the broader term, to

distinguish it from Medicare “telehealth”

payment

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“Telemedicine”

• Provision of clinical services by

physicians/practitioners from a distance via

electronic communications

• Preamble to final rule contains this

definition – therefore, binding

13

“Telemedicine”

• Telemedicine services provided either:

– Simultaneously, i.e., real time patient

assessment, prescribing treatment, etc., similar

to actions of on-site physician/practitioner

(Example: teleICU)

– Non-simultaneously, i.e., upon formal request

from attending, but may involve after-the-fact

interpretations or assessments of diagnostic

tests, etc., similar to on-site consultant

(Example: teleradiology)

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“Distant-site”

• “Distant-site” refers to the location of the

physician or practitioner who is providing

telemedicine services to a hospital’s or

CAH’s patients

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“Telemedicine Entity”

• An entity that:

1. Provides telemedicine services;

2. Is NOT a Medicare-participating hospital

3. Provides contracted services in a manner that

enables a hospital or CAH using its services to

comply with all applicable CoPs, particularly

those for credentialing and privileging

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“Telemedicine Entity”

• Unlike distant-site hospitals, “telemedicine

entities” do not participate as such in

Medicare and are not subject to CMS

oversight

• The telemedicine rules permit agreements

with these entities, but also recognize the

special accountability challenges they raise

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Telemedicine Agreements

• Hospitals/CAHs may only offer

telemedicine services if:

– Services are provided by a distant-site

Medicare-participating hospital or telemedicine

entity; and

– There is a written agreement between the

hospital or CAH and the distant-site hospital or

telemedicine entity. Agreements must include

certain provisions

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Telemedicine Agreements

• Agreements with telemedicine entities must

state:

– The entity is a contractor of services to the

hospital or CAH; and

– It furnishes contracted services in a way that

permits the hospital/CAH to comply with all

applicable CoPs, particularly those related to

telemedicine physicians/practitioners

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Telemedicine Agreements

• The required substance ends up mostly the

same for all telemedicine agreements, but

the regulations read differently due to:

– Underlying hospital/CAH CoP differences for

staffing and privileging

– Differences between a hospital & telemedicine

entity

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Hospital vs CAH Privileging

• Hospitals have a medical staff consisting of

physicians which may also include non-

physician practitioners

• CAHs have a professional healthcare staff

consisting of ≥ 1 MD/DO & may also

include ≥ 1 PA, NP or clinical nurse

specialist

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“Standard” privileging process

Hospital Governing Body CAH Governing Body

1. Determines which categories of

physicians/practitioners eligible for

medical staff membership/privileges

If the CAH is in a rural health network, it

must have an agreement for credentialing

with an outside entity

2. Appoints members/grant privileges after

considering medical staff

recommendations

Grants professional healthcare staff

privileges

3. Assures Medical Staff has bylaws All CAHs must have agreement for outside

review of MD/DO clinical services for quality,

appropriateness

4. Approves Medical Staff bylaws,

rules/regulations

CAH must consider findings of outside

review

5. Ensures medical staff accountable for

quality of care

6. Ensures criteria for privileges are

individual character, competence,

training, experience & judgment

7. Ensures privileges not solely dependent

upon board certification

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“Standard” privileging process

Hospital Medical Staff CAH Prof. Healthcare Staff

Must examine credentials of candidates for

membership/privileges & make

recommendations to governing body

No required role in recommending

professional healthcare staff privileges

Must periodically appraise

physicians/practitioners with current

privileges/membership

MD or DO on CAH’s professional healthcare

staff, or under contract to CAH, evaluates

quality & appropriateness of services by NP,

PA and/or clinical nurse specialists on the

professional healthcare staff

Must have governing body-approved by-

laws including

•statement of duties/privileges of each

category of medical staff

•Candidate qualifications that must be

met for the medical staff to

recommend appointment/privileges

•Criteria for determining privileges to

be granted to individual practitioners &

procedure to apply the criteria to

individual applicants

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Hospital Telemedicine Agreement

Required Provisions

• Hospital agreements with both distant-site hospital

or telemedicine entity must state the distant site’s

governing body ensures the same 7 governing

body medical staff requirements are met for its

telemedicine physicians/practitioners as in the

“standard” hospital privileging process

– For distant-site hospitals, which must

participate in Medicare, there are no new

requirements

– For distant-site telemedicine entities, this may

be a change from their current practice

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CAH Telemedicine Agreement

Required Provisions

• Agreement must state that the governing body of

the distant-site hospital ensures the 7 medical staff

requirements are met for its telemedicine

physicians/practitioners, i.e., the “standard”

hospital medical staff requirements

• These 7 requirements also must be included in

agreements with distant-site telemedicine entities

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Other CAH Requirements

• CAHs may provide services under

agreements or arrangements only with a

Medicare-participating provider or supplier

• Since telemedicine entities by definition do

not participate in Medicare, an exception to

this requirement is provided for

agreements with telemedicine entities

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Privileging Requirements

• All telemedicine physicians/practitioners

must be granted privileges in the hospital

or CAH where the patient receiving

telemedicine services is located

• Privileges must be aligned with services

provided – e.g., no telemedicine surgical

privileges!

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Telemedicine Privileging Options

• Hospitals & CAHs can choose between:

– Following their standard privileging process;

– Expedited telemedicine privileging, relying on

privileges granted by distant site

• Distant site may not compel use of

expedited privileging

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Hospital Expedited

Telemedicine Privileging Distant Site

Hospital Telemedicine Entity

Governing body may

act on medical staff

recommendations

relying on the distant

site’s privileging

decisions if it ensures

through its written

agreement that:

1. Distant-site hospital

participates in Medicare

2. Physician/practitioner is

privileged at distant site,

which provides current

list of their privileges

3. Physician/practitioner

holds license

issued/recognized by

State where patient is

4. Hospital has evidence of

review of telemedicine

physician/practitioner

performance and sends

to distant site for its use

in periodic reappraisal

1. Same conditions as

distant site hospital #2-

4, plus:

2. Entity is a contractor

providing services

permitting hospital to

comply with CoPs

3. Entity’s privileging

process meets hospital

privileging requirements

(7 points above, plus

entity’s medical staff

must periodically

conduct appraisals of its

members, examine

credentials of

candidates & make

recommendations to the

entity’s governing body)

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CAH Expedited

Telemedicine Privileging

Distant Site

Hospital Telemedicine Entity

Governing body may

rely on distant site’s

privileging decisions if

it ensures through its

written agreement

that:

1. Distant-site hospital

participates in Medicare

2. Physician/practitioner is

privileged at distant site,

which provides current

list of their privileges

3. Physician/practitioner

holds license

issued/recognized by

State where patient is

4. CAH has evidence of

review of telemedicine

physician/practitioner

performance and sends

to distant-site hospital

for its use in periodic

reappraisal

1. Same as #2-4 for distant

site hospital

2. Distant-site telemedicine

entity’s medical staff

privileging process

meets the 7 points

above

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Hospital vs CAH

• Primary differences stem from the role of

the medical staff in the privileging process

of hospitals

• Many CAHs choose to involve the

physicians on their professional healthcare

staff in privileging, but the CAH CoPs do

not mandate

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CAH Reappraisal

• CAHs must have an agreement with an

outside entity to review the quality and

appropriateness of the diagnosis and

treatment furnished by MDs/DOs: – A network hospital, if applicable

– A QIO or equivalent

– Another appropriate, qualified entity identified in the State

rural health care plan

– A distant-site hospital – only for telemedicine physicians

under the hospital’s agreement with the CAH

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CAH Reappraisal

• Note that distant-site telemedicine entity

may not conduct the outside review of the

telemedicine services provided under its

agreement with the CAH

– Review must be by network hospital, QIO or

other entity designated in State plan

– Review required for each MD/DO who provided

telemedicine services during the review period

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CAH Reappraisal

• CAH medical records and privileging files

should suffice to conduct the outside

review

– Not necessary for outside reviewer to go to the

distant-site telemedicine entity

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Q’s & A’s

• Who is responsible for enforcing the written

agreement? Will surveyors go to the

distant-site?

• The hospital or CAH is responsible for

holding its contractor to the terms of the

agreement. State surveyors will not go to

the distant site to verify, but will look at the

information the hospital or CAH has

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Q’s & A’s

• Can the expedited privileging process also be

used to grant medical staff/professional

healthcare staff privileges for people who practice

on-site at a hospital or CAH?

• No – the standard credentialing and privileging

process must be used for hospital and CAH

physicians/practitioners who practice on-site at the

hospital or CAH

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Q’s & A’s

• Must the hospital or CAH maintain a separate file

on each telemedicine physician and practitioner

who holds privileges granted under the expedited

process?

• No – the hospital may as an alternative maintain

one up-to-date file for each telemedicine

agreement that contains the list of the

telemedicine physicians and practitioners covered

by the agreement, including the current privileges

the hospital or CAH has granted each of them

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Q’s & A’s

• Can an accreditation organization require a

hospital or CAH to use the expedited

process and accept the privileging

decisions of the distant site?

• No – the regulation specifically states that

the hospital or CAH governing body “may”

rely on the privileging decisions of the

distant site; it is not required to do so &

AOs may not impose this requirement

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Q’s & A’s

• If both the hospital or CAH and the distant-

site hospital or telemedicine entity are both

accredited by the same AO, does there still

need to be a written agreement covering

telemedicine services?

• Yes, the regulation requires a written

agreement that contains all of the required

elements discussed above

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Q’s & A’s

• Can an AO require its accredited hospital

or CAH to use the expedited privileging

process only when the distant-site is also

accredited by that AO?

• CMS rules neither address nor prohibit this

AO business practice

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Q’s & A’s

• Does the medical staff still need to make a

recommendation concerning privileges for

telemedicine physicians/practitioners?

• For hospitals – yes, but the medical staff may rely

on the distant-site’s privileging decisions in making

its recommendation

• For CAHs – no, since there is no requirement for

the professional healthcare staff to make

recommendations in its regular privileging process

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Q’s & A’s

• What happens if the distant-site hospital’s

participation in Medicare ends, either

voluntarily or involuntarily?

• The hospital or CAH may no longer receive

telemedicine services as of the effective

date of termination of Medicare

participation

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Q’s & A’s

• Can a distant-site hospital or telemedicine

entity include on the list of physicians &

practitioners covered by the agreement

people who do not hold privileges at the

distant site?

• No – all physicians/practitioners covered by

the agreement must hold privileges at the

distant site

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Q’s & A’s

• How often does the distant-site have to

provide a list of the covered telemedicine

physicians/practitioners to the hospital or

CAH?

• The hospital’s or CAH’s list must be

current. The agreement with the distant-

site must address how the list will be kept

current.

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Q’s & A’s

• What does the hospital or CAH review of

telemedicine services consist of?

• At a minimum, the hospital or CAH must review

and send to the distant site information on all:

– adverse events that result from provision of

telemedicine services under the agreement;

and

– Complaints about a telemedicine physician or

practitioner

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Telemedicine Privileging Rules

Other Questions?

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