Accreditation Standards related to telemedicine expand an acute care hospital’s ability to give patients access to practitioners who work elsewhere but whose expertise patients need. That expanded access also comes with requirements for credentials and privileges.
Accreditation Commission for Health Care (ACHC) Standards for an acute care hospital offering this type of telemedicine services to its patients require written agreements. The agreement must specify the responsibility of the distant-site hospital’s governing body to satisfy all requirements for medical staff membership and privileging (§482.12(a)(1)-(7)), or the agreement must specify that the distant-site entity will furnish services in a manner that permits the hospital to comply with Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs), including all requirements for medical staff membership and privileging (§482.12(a)(1)-(7)).
The hospital’s governing body must grant privileges to each telemedicine physician or practitioner providing services at the hospital under an agreement with a distant-site hospital or telemedicine entity before they may provide telemedicine services. The scope of privileges in the hospital must reflect the provision of the services via a telecommunications system. The written agreement must also specify the method for reviewing and recommending credentialing and privileging decisions.
The hospital may use a delegated or non-delegated process to grant privileges to telemedicine practitioners.
Delegated Credentialing and Privileging Process
The hospital’s governing body may grant privileges based on recommendations by its medical staff that rely upon the privileging decisions of a distant-site telemedicine hospital or entity.
If the governing body exercises this option, it may have one file that lists all telemedicine physicians/practitioners and indicates which telemedicine privileges the hospital has granted to each.
The distant-site hospital must participate in the Medicare program, or the distant-site entity must use a medical staff credentialing and privileging process that is compliant with the CoPs.
The distant-site hospital/entity must provide a list of all its physicians and practitioners and their privileges covered in the agreement. The list must be current, so the agreement must address how the distant site will keep the list current.
Practitioners providing services must be privileged at the distant-site hospital/entity.
Each physician/practitioner must have an active license in the state where the hospital is located and the state where the practitioner is located.
The acute care hospital is required to review the telemedicine services and provide feedback to the distant site to be used in the periodic appraisal of the providers.
This delegated credentialing and privileging process must be outlined in the hospital’s medical staff bylaws.
Non-Delegated Credentialing and Privileging Process
The acute care hospital’s governing body may require its medical staff to independently review the credentials and make privileging recommendations for each telemedicine physician/practitioner.
The telemedicine agreement must indicate that the acute care hospital will independently review credentials rather than relying on privileging decisions by a distant-site hospital/entity.
A separate credentials file must be maintained for each telemedicine practitioner.
All telemedicine practitioners must follow the credentialing and privileging process outlined by the hospital just as any other physician/practitioner providing care at the facility. The medical staff is required to thoroughly and separately verify and examine the credentials of each practitioner applying for privileges.
This includes but is not limited to the following requirements for examination of credentials, application/reapplication, ongoing professional practice evaluation (OPPE), and focused professional practice evaluation (FPPE).
The telemedicine provider must have an active license in the state where the acute care hospital is located and the state where the practitioner is located.
When determining which process to use, the hospital should refer to ACHC Standards 01.01.08, 03.00.08, and 03.00.09 for more detailed information.
Tips for Compliance
Ensure that the written agreement includes the requirements outlined above.
When an acute care hospital uses a delegated process, ensure a process is in place to keep the list of telemedicine physicians/practitioners current. This process should be outlined in the written agreement.
When an acute care hospital uses a delegated process, ensure that feedback is provided to the distant site. At minimum, this must include information on all adverse events that result from the provider’s provision of services and complaints received about a telemedicine provider.
Each acute care hospital should audit the telemedicine privileges granted by its governing body to ensure compliance with these requirements. These audits should be an essential part of your organization’s survey preparation process.
Here to Help
To access the most recent ACHC Accreditation Standards Manual, please contact your Account Advisor or email us at customerservice@achc.org.
Prepublication of Standards Updates Coming in July
Prepublication of updated ACHC Acute Care Hospital Standards is expected to take place in July 2022.
The tentative effective date will be no earlier than October 2022, subject to change based on CMS approval.
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