CMS to ease burden on credentialing, privileging of telemedicine providers?
September 1, 2010 8 minutes read
CMS to ease burden on credentialing, privileging of telemedicine providers?
Proposed change accepts third-party verification
Requirements for credentialing and privileging telemedicine providers are up in the air for now, following the May 26 release of a proposed rule from the Centers for Medicare & Medicaid Services (CMS).
When CMS approved The Joint Commission's application for continued deeming authority in November 2009, Margaret VanAmringe, MHS, The Joint Commission's vice president for public policy and government relations, told Hospital Peer Review there were certain areas the organizations still had to work on to come more in line. (See HPR cover story, January 2010.) At the time, VanAmringe expressed hope that CMS would change some of its standards to be more in tune with The Joint Commission's, specifically citing the area of telemedicine.
It looks like that's happening, with a change many say will reduce a significant burden on hospitals and critical access hospitals. CMS' proposed rule, much like The Joint Commission standards, would revise CMS Conditions of Participation (CoPs), allowing hospitals to accept third-party verification on credentialing and privileging of telemedicine providers (see http://edocket.access.gpo.gov/2010/2010-12647.htm).
"The Joint Commission had been notifying hospitals that as of July 15, they would no longer be permitted to credential and privilege telemedicine practitioners by proxy, which had been permitted under Joint Commission standards," says Kevin J. Eldridge, attorney in the health law group of Quarles & Brady LLP in Madison, WI. But in June, TJC delayed implementation of CMS telemedicine requirements until March 2011 for its accredited hospitals contingent on CMS' proposed changes
Will the changes ease workload on hospitals?
The Joint Commission "had allowed facilities that were receiving telemedicine services (those are called the originating sites, where the patient is located) to accept the credentialing and privileging of the consultant at what's called the distant site 'by proxy,'" says Dale Alverson, MD, president of the American Telemedicine Association (ATA) and faculty of the University of New Mexico. "That made sense because, one, it relieved the originating site, the smaller hospitals, of the burden of attempting to credential and privilege every possible telemedicine provider, which could be a fairly significant burden." CMS, however, had mandated that every telemedicine provider be fully credentialed and privileged at any site where they provided services.
"So that was in conflict with The Joint Commission. And [CMS] was going to require The Joint Commission to come into compliance with their rules. This was a huge concern to the telehealth community, as well as those providing or receiving telehealth services," Alverson says. "CMS listened and came out with a notice of proposed rule-making that would allow hospitals and critical access hospitals to accept credentialing and privileging from the distant site." Comments on the proposed rule closed July 26, and most expect the final rule to come out in November.
To illustrate the burden of credentialing and privileging every individual telemedicine provider, Alverson says "we have 500 physicians on faculty here at our health sciences center. And let's say, for the sake of argument, they were all providing telemedicine services to every hospital in the state. That's 50. So you can do the math 50 times 500. You'd have to do at least every two years 25,000 credentialing and privileging packages."
Many experts, including Eldridge, agree that the proposed rule will ease the burden for hospitals, especially for smaller, more rural critical access hospitals, and the comments on the proposed rule seem to support that, he says. "Even CMS agrees," he says. "In reversing its course on telemedicine, CMS admitted that its current process for credentialing and privileging telemedicine practitioners is 'duplicative and burdensome' for both hospitals and telemedicine."
A spokesperson from the National Association Medical Staff Services (NAMSS) told HPR, "the proposed rule appears to ease the upfront administrative burden of collecting credentialing data for distant-site hospitals. However, both the distant site and the originating site still carry the responsibility of ensuring that they are providing their medical staff with the best information for making privileging decisions. For the originating site, this means collecting and verifying all the data. For the distant site, this means ensuring that the originating site is in good standing with CMS and can be relied upon to produce a verified credentialing file and solid privileging decision."
Patrick Hurd, JD, senior counsel and leader of the Healthcare Industry Group with the law firm of LeClair Ryan in Norfolk, VA, isn't sure how the change will affect hospitals. "It remains to be seen," he says. "I do think it will help critical access hospitals, who are typically more reliant on telemedicine services. Based on my work with clients to date, there remains much skepticism that the CMS rule will be of much help."
Elements of rule changes
The CMS proposed rule requires constant monitoring and communication between the originating and distant site. The distant site must be a Medicare-participating hospital. Internal reviews, adverse events, and grievances at the originating site must be shared with the distant site. Also, if any providers lose or have a change in their credentialing and privileging status, that would be shared as well with the distant site. Specifically, CMS' proposed rule stipulates that these criteria are met:
- "The distant-site hospital providing the telemedicine services is a Medicare-participating hospital"
- "the individual distant-site physician or practitioner is privileged at the distant-site hospital providing telemedicine services, and that this distant-site hospital provides a current list of the physician's or practitioner's privileges"
- "the individual distant-site physician or practitioner holds a license issued or recognized by the state in which the hospital, whose patients are receiving the telemedicine services, is located"
- "with respect to a distant-site physician or practitioner granted privileges by the hospital, the hospital has evidence of an internal review of the distant-site physician's or practitioner's performance of these privileges and sends the distant-site hospital this information for use in its periodic appraisal of the individual distant-site physician or practitioner. We are also proposing, at a minimum, the information sent for use in the periodic appraisal would have to include all adverse events that may result from telemedicine services provided by the distant-site physician or practitioner to the hospital's patients and all complaints the hospital has received about the distant-site physician or practitioner."
The Joint Commission's previous standards allowed by-proxy credentialing and privileging, and hospitals had the choice whether to handle it through a third party or on their own. With the CMS proposed rule, the same is true.
Hurd points out that in the proposed rule "the distant-site hospital's governing body has responsibility for assuring compliance with the CMS requirements, but the ultimate responsibility remains with the governing body of the hospital as to whether to rely on the distant-site hospital's credentialing and privileging information or conduct its own review."
Eldrige says that the current proposed rule brings CMS and The Joint Commission requirements more in line, but does not make them identical in every sense. "For example, CMS would permit privileging by proxy only between two hospitals, while existing Joint Commission standards permit privileging by proxy between Joint Commission-accredited hospitals and ambulatory care organizations."
Alverson, too, notes concern that CMS' rule covers only hospitals and critical access hospitals but does not include other facilities such as clinics or ambulatory care centers. The CMS rule applies only to hospital-hospital arrangements.
"That's one of the things that we were commenting on. We'd like to see them not just restrict it to hospitals and critical access hospitals, but to any clinical site where services are provided through telemedicine and are covered services by CMS. So that there wouldn't be a restriction on credentialing and privileging at the ambulatory sites as well," he says.
Proposed rule may face challenges
Hurd says although the proposed rule would indeed shorten the time and expense of credentialing telemedicine providers, it could face some challenges. "Some of the challenges of the CMS proposed rule, as opposed to The Joint Commission [elements of performance] include the current reluctance among hospitals to share their credentialing and privileging with another hospital, especially if that hospital is a competitor. The CMS proposed rule requires the sharing of adverse information and complaints regarding the telemedicine physician matters that currently remain under wraps even within the distant-site credentialing hospital.
"Also, although the credentialing and privileging committee of a hospital may receive information from its peer review committee as part of its review of the physician, it remains to be seen whether such information can or should be shared with the requesting hospital. It raises questions of privilege under varying state laws. There could be added complications if the physician at the distant-site hospital is under investigation by that facility but his or her privileges have not yet been revoked or suspended, delaying the sharing of information with the requesting hospital. On the other hand, if shared, beyond issues of confidentiality and privilege, it may result in refusal of privileges at the requesting hospital, creating additional and vexing legal and policy problems."
He recommends quality improvement departments familiarize themselves with the proposed rule and ensure "that medical staff executive committees, department chairs, or even the full medical staff are aware of these potential changes and begin to anticipate necessary revisions to bylaws, policies, and procedures." While there may be changes with the final rule, he also suggests hospitals that "may be in the position of receiving requests for adverse events, complaints, and other information on their credentialed physician staff" review their bylaws and policies "to assure that they accommodate the new challenges" of the new rule.
He also suggests that credentialing and privileging committees audit their current practices to assess whether under the current CMS provisions there have been any "significant difficulties and substantial delays in credentialing" to decide whether to continue independent credentialing and privileging or do it by proxy.
NAMSS is requesting clarification on parts of the proposed rule, including:
- how to verify whether the distant-site hospital is not only a Medicare-participating hospital but is in good standing;
- a further definition of "periodic appraisal" and whether that appraisal will be in accordance with standards for reappointment or must be a separate schedule for telemedicine providers.
Alverson questions: "How does the originating site document that they're accepting credentialing and privileging? Do they need a written document on file? What needs to be in place to satisfy CMS?"
Eldrige says as "CMS hammers out the final rule," hospitals may be confused "as to how to proceed with credentialing and privileging telemedicine practitioners."
Alverson says another area these changes may affect is licensing. "Interstate licensure and licensure portability is going to be another important area for exploration. And we're currently working with the Federation of State Medical Boards in that arena. So they're doing some pilot studies now of looking at how we can make it easier for telemedicine providers to offer services in other states."
CMS and the future of telemedicine
Alverson says CMS senior executive Barry Straube spoke to the board of ATA. "It was a sense of a greater interest in having dialogue between the users of telemedicine and advocates of telemedicine with other federal agencies like CMS," he says.
"I think [CMS is] seriously looking at the fact that we can improve continuity of care using telemedicine, we can detect problems earlier, we can intervene in a more timely manner and avoid subsequently more expensive care. Then the system begins to save money.
"And I think with health care reform, this is an important aspect of how do we improve access to care to all Americans, and one of the ways we can do that is look seriously at how we use health information technologies and telemedicine in a meaningful way. So I think they're taking that seriously."
Requirements for credentialing and privileging telemedicine providers are up in the air for now, following the May 26 release of a proposed rule from the Centers for Medicare & Medicaid Services (CMS).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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