CMS changes telemedicine credentialing rules

Rural facilities should find new ease in using this technology

The Centers for Medicare & Medicaid Services (CMS) in July released a final rule related to credentialing and privileges for providers delivering care through telemedicine. The new regulation should make it easier for facilities to partner with hospitals and non-hospital telemedicine entities such as teleradiology facilities to deliver care to their patients and deliver care to patients who might be hours away from a needed specialist.

The change goes back to 2004, when the Joint Commission said it was fine for hospitals to share credentialing when making use of telemedicine. A physician at one hospital who had credentials and privileges could use those to provide care remotely at another hospital. But when TJC lost its permanent deeming authority, CMS required the commission dial back on that ruling and come in line with its own rules regarding telemedicine credentialing as a requirement for gaining deeming authority again. CMS rules required hospitals to credential and grant privileges to remote-site doctors who were already credentialed in the facilities where they worked. That required recommendations from the medical staff of the hospital seeking the telemedicine consultation before they could consult. In an emergent situation, that was an impediment to timely care and could be expensive for small facilities, according to those who use telemedicine in their hospitals.

Now, a facility seeking telemedicine help from a provider at a remote site can use the credentials and privileges of that remote site instead of having to re-credential and privilege the physician.

The impact of the rule is undoubtedly positive, says Nancy Foster, vice president for quality and patient safety at the American Hospital Association (AHA). "This wasn't everything we wanted, but it is a big step forward," she says. "The requirement as it had been interpreted previously precluded many organizations from taking advantage of telemedicine opportunities. This is vital to help them."

Beyond assisting in existing uses of telemedicine, Foster says this may also help hospitals explore other potential uses of telemedicine — using it to follow up with patients who have been transferred back to the rural community, to connect with the patient's primary care physician, or to help patients with ongoing chronic conditions in non-emergent situations.

The latter is something that Grande Ronde Hospital in La Grande, OR, is already doing and may well expand, says Sarah Hall, BA RHIT, health information management director at the 25-bed hospital in rural Eastern Oregon. It's a three-hour drive to most specialists for residents of the area, and while about half the facility's use of telemedicine is for emergent cases, it is doing more and more non-emergent work, using robotic technology to schedule specialist consultations on a regular basis — a dermatologist three times a month, a rheumatologist every week. The hospital has won both state and national awards for its use of telemedicine.

Grande Ronde uses the same providers over and over again — several times every week, Hall says — and this new rule won't really make a difference to the hospital now, says Hall. But if telemedicine expands, this could be a way to save money and time, and care for more patients without having to transfer them to larger facilities or send them on a three-hour trek to Boise, the nearest big city.

To the border and no further — for now

Foster says the one thing she would have liked to see is the ability to use specialists who have been credentialed in other countries, as well. In situations that occur during the wee hours of the morning, a global specialist in Australia or Great Britain might be a better option than waking up someone in this country.

And while it welcomes this change, the AHA has been pushing for CMS to stop making minor changes to the conditions of participation and do an overhaul instead, says Lisa Grabbert, senior associate director for policy at the organization. "They haven't been changed since 1985. We would like them to think more globally — don't look at the telemedicine CoP, but look at better ways to handle transitions of care, which might include telemedicine."

The Center for Telehealth and E-Health Law was in the middle of the negotiations to get the changes made, says Greg Billings, senior director at the Washington, DC-based organization. "If they hadn't done this, I think it is safe to say that most telemedicine programs would have been significantly adversely impacted."

It makes no financial sense to have to credential a bunch of physicians who may or may not do work remotely for your hospital, and it makes no logical sense to ask a small hospital with a tiny staff to judge credentials of specialists at large teaching institutions who have more experience than they do, Billings says. "They choose to ask for help from these people because they have expertise the initiating hospital does not," he adds.

Initially, the rule change was geared to Medicare-participating hospitals alone. But comments on proposed rules brought up consideration for ambulatory care facilities and free-standing teleradiology clinics. Billings says that the final rule makes it possible for them to do this, too — provided they meet certain criteria.

"The telemedicine community is very happy with what CMS did here," he says. "There was such a furor over the potential disaster, and relief that they averted it by changing the rule. But CMS heard us and showed they listened."

There are still some issues to be clarified, such as whether in an emergent situation, a hospital can appoint the remote person to its staff retroactively. And Billings says hospitals may have to make some bylaw revisions or amendments to reflect the new rules.

Will the newfound ease result in an "explosion" of telemedicine? No, says Billings. While some hospitals like Grande Ronde may be planning to make better use of the technology, growth like that comes of its own volition. If anything, he thinks this will help non-rural and critical access hospitals take note and see how they can use it.

Foster agrees. "I don't see why a medium-sized hospital or a large community hospital that doesn't have some needed expertise can't make use of this, too."

The complete final rule is available at http://www.cms.gov/CFCsAndCoPs/06_Hospitals.asp and http://www.cms.gov/CFCsAndCoPs/03_CAHs.asp.

For more information on this topic, contact:

  • Nancy Foster, Vice President for Quality and Patient Safety, American Hospital Association, Washington, DC. Email: nfoster@aha.org, telephone: (202) 626-2337.
  • Lisa Grabbert, Senior Associate Director for Policy, American Hospital Association, Washington, DC. Email: lgrabbert@aha.org.
  • Sarah Hall, BA RHIT, Health Information Management Director, Grande Ronde Hospital, La Grande, OR. Email: sch03@grh.org. Telephone: (541) 963-1512.
  • Greg Billings, Senior Director, Center for Telehealth and E-Health Law, Washington, DC. Email: Greg.Billings@DBR.com. Telephone: (202) 230-5104.