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

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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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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. “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. “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. “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. “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. “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. 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. 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. 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. 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. “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. “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. 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. 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. 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. 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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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
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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. 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
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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. 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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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
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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. 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. 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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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. 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. 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. 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. 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. 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. 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. 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.
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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
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46. Telemedicine Privileging Rules
Other Questions?
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