Privileging Telemedicine
Practitioners in Hospitals/CAHs
Jeannie Miller, RN, MPH
Deputy Director, Clinical Standards Group...
Disclosure
• This presentation includes discussion of the impact of new
regulations on hospitals & CAHs that demonstrate
c...
Context
• Hospitals & critical access hospitals
(CAHs) must comply with Medicare
Conditions of Participation (CoPs) in ord...
Context
• Separate CoPs for:
– Hospitals (42 CFR Part 482)
– CAHs (42 CFR Part 485, Subpart F)

• CoPs apply to care provi...
Context
• Hospitals/CAHs have 2 options to
demonstrate compliance with the CoPs,
i.e., assessment by:
– State Survey Agenc...
Context
• Accreditation option is voluntary, but can
be a faster means for new facilities to enroll
in Medicare
• 85% of h...
Context
• When the CoPs change:
– CMS revises its official guidance on applying
the CoPs, the State Operations Manual; and...
Telemedicine Privileging Rules
• CMS proposed revisions to hospital and
CAH regulations governing telemedicine
privileging...
Telemedicine Privileging Rules
• New rules aim to increase patient access to care
while reducing duplicative burdens on ho...
Telemedicine Privileging Rules
• Final rule adopted May 5, 2011 (76 FR
25550)
– Can access at:
http://www.gpo.gov/fdsys/pk...
Telemedicine Guidance
• CMS issued its interpretive guidelines for
the revised CoPs on July 15, 2011
– Can access at:
http...
Key Terminology
• “Telemedicine” vs. “telehealth”
– Industry uses “telehealth” as the broader term
– But Social Security A...
“Telemedicine”

• Provision of clinical services by
physicians/practitioners from a distance via
electronic communications...
“Telemedicine”
• Telemedicine services provided either:
– Simultaneously, i.e., real time patient
assessment, prescribing ...
“Distant-site”

• “Distant-site” refers to the location of the
physician or practitioner who is providing
telemedicine ser...
“Telemedicine Entity”
• An entity that:
1. Provides telemedicine services;
2. Is NOT a Medicare-participating hospital
3. ...
“Telemedicine Entity”
• Unlike distant-site hospitals, “telemedicine
entities” do not participate as such in
Medicare and ...
Telemedicine Agreements
• Hospitals/CAHs may only offer
telemedicine services if:
– Services are provided by a distant-sit...
Telemedicine Agreements
• Agreements with telemedicine entities must
state:
– The entity is a contractor of services to th...
Telemedicine Agreements
• The required substance ends up mostly the
same for all telemedicine agreements, but
the regulati...
Hospital vs CAH Privileging
• Hospitals have a medical staff consisting of
physicians which may also include nonphysician ...
“Standard” privileging process
Hospital Governing Body

CAH Governing Body

1.

Determines which categories of
physicians/...
“Standard” privileging process
Hospital Medical Staff

CAH Prof. Healthcare Staff

Must examine credentials of candidates ...
Hospital Telemedicine Agreement
Required Provisions
• Hospital agreements with both distant-site hospital
or telemedicine ...
CAH Telemedicine Agreement
Required Provisions
• Agreement must state that the governing body of
the distant-site hospital...
Other CAH Requirements
• CAHs may provide services under
agreements or arrangements only with a
Medicare-participating pro...
Privileging Requirements

• All telemedicine physicians/practitioners
must be granted privileges in the hospital
or CAH wh...
Telemedicine Privileging Options
• Hospitals & CAHs can choose between:
– Following their standard privileging process;
– ...
Hospital Expedited
Telemedicine Privileging
Distant Site
Hospital
1.

Governing body may
act on medical staff
recommendati...
CAH Expedited
Telemedicine Privileging
Distant Site
Hospital
Governing body may
rely on distant site’s
privileging decisio...
Hospital vs CAH
• Primary differences stem from the role of
the medical staff in the privileging process
of hospitals
• Ma...
CAH Reappraisal
• CAHs must have an agreement with an
outside entity to review the quality and
appropriateness of the diag...
CAH Reappraisal
• Note that distant-site telemedicine entity
may not conduct the outside review of the
telemedicine servic...
CAH Reappraisal
• CAH medical records and privileging files
should suffice to conduct the outside
review
– Not necessary f...
Q’s & A’s
• Who is responsible for enforcing the written
agreement? Will surveyors go to the
distant-site?
• The hospital ...
Q’s & A’s
• Can the expedited privileging process also be
used to grant medical staff/professional
healthcare staff privil...
Q’s & A’s
• Must the hospital or CAH maintain a separate file
on each telemedicine physician and practitioner
who holds pr...
Q’s & A’s
• Can an accreditation organization require a
hospital or CAH to use the expedited
process and accept the privil...
Q’s & A’s
• If both the hospital or CAH and the distantsite hospital or telemedicine entity are both
accredited by the sam...
Q’s & A’s
• Can an AO require its accredited hospital
or CAH to use the expedited privileging
process only when the distan...
Q’s & A’s
• Does the medical staff still need to make a
recommendation concerning privileges for
telemedicine physicians/p...
Q’s & A’s
• What happens if the distant-site hospital’s
participation in Medicare ends, either
voluntarily or involuntaril...
Q’s & A’s
• Can a distant-site hospital or telemedicine
entity include on the list of physicians &
practitioners covered b...
Q’s & A’s
• How often does the distant-site have to
provide a list of the covered telemedicine
physicians/practitioners to...
Q’s & A’s
• What does the hospital or CAH review of
telemedicine services consist of?
• At a minimum, the hospital or CAH ...
Telemedicine Privileging Rules

Other Questions?

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Privileging Telemedicine Practitioners in Hospitals/CAHs

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Presentation by Jeannie Miller, RN, MPH, Deputy Director, Clinical Standards Group, Office of Clinical Standards and Quality, Centers for Medicare & Medicaid Services

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Privileging Telemedicine Practitioners in Hospitals/CAHs

  1. 1. 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
  2. 2. 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 CMSapproved 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
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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 7
  8. 8. 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 8
  9. 9. 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
  10. 10. Telemedicine Privileging Rules • Final rule adopted May 5, 2011 (76 FR 25550) – Can access at: http://www.gpo.gov/fdsys/pkg/FR-2011-0505/pdf/2011-10875.pdf • Effective July 5, 2011 10
  11. 11. 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 11
  12. 12. 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 12
  13. 13. “Telemedicine” • Provision of clinical services by physicians/practitioners from a distance via electronic communications • Preamble to final rule contains this definition – therefore, binding 13
  14. 14. “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) 14
  15. 15. “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 15
  16. 16. “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 16
  17. 17. “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 17
  18. 18. 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 18
  19. 19. 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 19
  20. 20. 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 20
  21. 21. Hospital vs CAH Privileging • Hospitals have a medical staff consisting of physicians which may also include nonphysician practitioners • CAHs have a professional healthcare staff consisting of ≥ 1 MD/DO & may also include ≥ 1 PA, NP or clinical nurse specialist 21
  22. 22. “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 22
  23. 23. “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 bylaws 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 23
  24. 24. 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 24
  25. 25. 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 25
  26. 26. 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 26
  27. 27. 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! 27
  28. 28. 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 28
  29. 29. Hospital Expedited Telemedicine Privileging Distant Site Hospital 1. Governing body may act on medical staff recommendations relying on the distant site’s privileging decisions if it ensures through its written agreement that: 2. 3. 4. Distant-site hospital participates in Medicare Physician/practitioner is privileged at distant site, which provides current list of their privileges Physician/practitioner holds license issued/recognized by State where patient is Hospital has evidence of review of telemedicine physician/practitioner performance and sends to distant site for its use in periodic reappraisal Telemedicine Entity 1. 2. 3. Same conditions as distant site hospital #24, plus: Entity is a contractor providing services permitting hospital to comply with CoPs 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) 29
  30. 30. CAH Expedited Telemedicine Privileging Distant Site Hospital Governing body may rely on distant site’s privileging decisions if it ensures through its written agreement that: 1. 2. 3. 4. Distant-site hospital participates in Medicare Physician/practitioner is privileged at distant site, which provides current list of their privileges Physician/practitioner holds license issued/recognized by State where patient is CAH has evidence of review of telemedicine physician/practitioner performance and sends to distant-site hospital for its use in periodic reappraisal Telemedicine Entity 1. 2. Same as #2-4 for distant site hospital Distant-site telemedicine entity’s medical staff privileging process meets the 7 points above 30
  31. 31. 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 31
  32. 32. 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 32
  33. 33. 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 33
  34. 34. 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 34
  35. 35. 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 35
  36. 36. 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 36
  37. 37. 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 37
  38. 38. 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 38
  39. 39. Q’s & A’s • If both the hospital or CAH and the distantsite 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 39
  40. 40. 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 40
  41. 41. 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 41
  42. 42. 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 42
  43. 43. 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 43
  44. 44. 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 distantsite must address how the list will be kept current. 44
  45. 45. 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 45
  46. 46. Telemedicine Privileging Rules Other Questions? 46

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