Credentialing and Privileging

Before a practitioner may provide services in a hospital, he or she must have their qualifications evaluated and verified.  This process, known as credentialing, ensures an individual possesses the necessary qualifications to provide medical services to patients. Once a practitioner is credentialed, the hospital engages in the privileging process, which will assess the practitioner’s competence in a specific area of care.

Telehealth providers, despite not being physically located at the hospital they are providing services to, must also go through the credentialing and privileging process for that distantly located institution.  To credential and privilege a physician can be lengthy and expensive, utilizing a good amount of resources.  However, hospitals that have limited access to specialists need to contract with practitioners in other locations to provide virtual care to their patients.  The alternative is that their patients have to travel to receive that care or go without.  Telehealth has helped these institutions provide such services while allowing a patient to remain in his or her community.  In the past, hospitals relied on “privileging by proxy” standards that The Joint Commission (TJC), a hospital accrediting organization, have utilized to make the credentialing and privileging process less burdensome on facilities utilizing telehealth.  The process allowed the hospital receiving services to accept the distant site (where the telehealth provider is located) hospital’s credentialing and privileging decisions.  It cut down on duplicative work and expense.

The Centers for Medicare & Medicaid Services (CMS) identified TJC’s privileging by proxy standards as being in conflict with their Medicare Conditions of Participation (CoPs). In order to participate in and receive reimbursement from the Medicare or Medicaid programs, a hospital must be certified as complying with the Medicare CoPs.  Therefore, TJC’s process was rendered invalid. This created a difficult situation for many hospitals, particularly small and rural entities who could not afford to hire exclusively on-site specialists to service their communities’ needs.

To resolve this conflict while still maintaining safeguards on quality and safety, CMS approved regulations in July 2011 that would allow hospitals (and other health care organizations) to use a similar credentialing-by-proxy process that the TJC had once utilized.  TJC followed suit with similar standards that were approved in December 2011.

The approved process is optional for hospitals to use.  Should an institution chose, it may still go through the complete credentialing and privileging process of verifying a practitioner’s qualifications.  However, if a hospital wished to utilize the credentialing by proxy process, certain requirements must be met:

  • There must be a written agreement between the two parties;
  • The distant-site hospital is a Medicare-participating hospital or telemedicine entity;
  • The telehealth provider is privileged at the distant-site hospital;
  • A current list of the telehealth provider’s privileges is given to the originating-site hospital;
  • The telehealth provider holds a license issued or is recognized by the state in which the originating-site hospital is located;
  • The originating-site hospital has an internal review of the telehealth provider’s performance and provides this information to the distant-site hospital;
  • The originating-site hospital must inform the distant-site hospital of all adverse events and complaints regarding the services provided by the telehealth provider.

Hospitals do need to ensure that their bylaws meet the requirements of this process.  Some organizations may find meeting these necessary requirements prohibitive in time and resources and choose not to utilize this optional process.

 

The applicable CMS regulations are:

 

TJC applicable standards:

  • Standard LD 04.03.09 - Care, treatment, and services provided through contractual agreement are provided safely and effectively.
  • Standard MS. 13.01.01 - For originating sites only: Licensed independent practitioners who are responsible for the care, treatment, and services of the patient via telemedicine link are subject to the credentialing and privileging processes of the originating site.