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Accreditation Commission for Health Care (ACHC) Standards for a critical access hospital (CAH) 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 critical access hospital to comply with Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs), including but not limited to the requirements of §485.635(c)(4)(ii). Under §485.635(c)(4)(ii), the CAH’s governing body or responsible individual is obligated to ensure that all contractors of services furnish those services in a manner that enables the CAH to comply with all applicable CoPs.

The critical access hospital’s governing body must grant privileges to each telemedicine physician or practitioner providing services at the facility under an agreement with a distant-site hospital or telemedicine entity before they may provide telemedicine services. The scope of privileges in the critical access 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 critical access hospital may use a delegated or non-delegated process to grant privileges to telemedicine practitioners.

Delegated Credentialing and Privileging Process

• The critical access hospital’s governing body has the option to 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 critical access 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 hospital/entity 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 CAH is located and the state where the practitioner is located.
• The CAH 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 CAH’s medical staff bylaws.

Non-Delegated Credentialing and Privileging Process

• The critical access 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 CAH 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 CAH 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 still must have an active license in the state where the CAH is located and the state where the practitioner is located.

When determining which process to use, the critical access hospital should refer to ACHC Standards 01.03.06, 01.03.07, 05.00.14, 05.01.11, and 06.07.00 for more detailed information.

Tips for Compliance

• Ensure that the written agreement includes the requirements outlined above.
• When a critical access 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 a critical access 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 CAH 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, please contact your Account Advisor or email us at customerservice@achc.org.

Prepublication of Standards Updates Coming in July

Prepublication of updated ACHC Critical Access 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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