Effective July 5, 2011, CMS will permit hospitals to credential and grant clinical privileges to a telemedicine practitioner based upon the credentialing and privileging decisions of another entity who provides the telemedicine services. If it so chooses, the hospital where the patient is located will no longer be required by CMS to independently verify and evaluate the qualifications of individuals who treat its patients.
The origin of changes to the credentialing and privileging processes for telemedicine providers can be traced back to 2003, when the Joint Commission revised its standards to allow practitioners who provided telemedicine services to be “credentialed and privileged by proxy.” This allowed a hospital where the patient was located to rely on the credentialing and privileging decisions of the distant-site hospital or telemedicine entity, the only requirement being that the entity where the telemedicine practitioner was located be accredited by the Joint Commission. Under the former Joint Commission Standards, the hospital was not even required to grant clinical privileges to these individuals. Instead, they could be permitted to practice pursuant to a contract between the telemedicine provider and the hospital.
CMS disagreed with the Joint Commission’s approach to telemedicine credentialing, believing it was in “direct conflict” with the Medicare Conditions of Participation (CoPs). CMS’s rationale was that telemedicine physicians provide a “medical level of care,” and by doing so, must be individually credentialed and privileged. CMS’s concern was that Medicare beneficiaries were receiving services at a hospital when nothing bound the providers of the services to comply with the Medicare CoPs for hospitals.
In reaction to this, in 2008, Congress passed the Medicare Improvements for Patients and Providers Act (MIPPA). Prior to MIPPA, the Joint Commission had unique “deeming authority” (any hospital accredited by the Joint Commission is “deemed” to be in compliance with the Medicare CoPs). MIPPA removed the Joint Commission’s unique deeming authority requiring the Joint Commission to reapply periodically to CMS for deeming authority.
In the fall of 2009, the Joint Commission revised its telemedicine standards to bring them into compliance with CMS requirements. However, even as the Joint Commission published its revised standards, it pledged to continue its lobbying efforts on behalf of “privileging by proxy” for telemedicine.
In May of 2010, before the revised Joint Commission standards went into effect, CMS published a proposed regulation regarding telemedicine credentialing. In the rule, CMS proposed to allow the hospital where the patient is located to rely on information provided by a Medicare-participating hospital where the telemedicine practitioner is located. The proposed rule was very restrictive in that it would not have permitted a hospital to rely on information provided by entities other than Medicare-participating hospitals, excluding teleradiology services through teleradiology groups.
CMS made major changes to the rule, and in the final regulation, CMS essentially adopted the Joint Commission’s idea of privileging by proxy, but with changes do require that telemedicine providers be bound by Medicare CoPs by agreement with the hospital. The final rule permits the medical staff of the hospital where the patient is located to make a recommendation to the governing board about a telemedicine practitioner that relies upon the credentialing and privileging decisions of the telemedicine provider. In turn, the governing board may rely upon the medical staff’s recommendation in granting privileges to the telemedicine practitioner. Thus, while the hospital where the patient is located must still grant privileges to the telemedicine practitioner, it may rely upon the decisions of other entities in doing so.
In light of this rule, hospitals may continue to fully credential and privilege telemedicine practitioners through their own medical staff process if they wish to do so. The final regulation simply means that they have the option of using a more streamlined process. If a hospital wishes to make use of the process now permitted by CMS, it must enter into a written agreement with the distant-site hospital or telemedicine entity that satisfies the requirements found in the rule.