Sample Letter Re: Hospital Privileges and Competency Validation for
Understanding Telemedicine Credentialing Options
Presented by:
Kathy Matzka, CPMSM, CPCS
Writer/Speaker/Consultant
1304 Scott Troy Road
Lebanon, IL 62254
www.kathymatzka.com
Phone (618) 624-8124
Fax (618) 624-8124
About the Presentor:
Kathy Matzka, CPMSM, CPCS is a speaker, consultant, and writer with almost 25 years of experience in credentialing, privileging, and medical staff services. She holds certification by the National Association Medical Staff Services (NAMSS) in both Medical Staff Management and Provider Credentialing. Ms. Matzka worked for 13 years as a hospital medical staff coordinator before venturing out on her own as a consultant, writer, and speaker.
Ms. Matzka has authored a number of books related to medical staff services including The Chapter Leader's Guide to Medical Staff: Practical Insight on Joint Commission Standards, The Compliance Guide to Joint Commission Medical Staff Standards, and The Medical Staff Meeting Companion: Tools and Techniques for Effective Presentations. For the past eight years, she has been the contributing editor for The Credentials Verification Desk Reference.
She has performed extensive work with NAMSS’ Library Team developing and editing educational materials related to the field including CPCS and CPMSM Certification Exam Preparatory Courses, CPMSM and CPCS Professional Development Workshops, and NAMSS Core Curriculum. These programs are essential educational tools for both new and seasoned medical services professionals. She also serves as instructor for NAMSS.
Ms. Matzka shares her expertise by serving on the editorial advisory boards for three publications - Briefings on Credentialing, Credentialing, Peer Review Legal Insider, and Advisor for Medical and Professional Staff Services. She is a member of the advisory board of Global Health Sources, where she serves as an expert in provider credentialing, privileging, and other aspects of medical staff management
Ms. Matzka is a highly-regarded industry speaker, and in this role has developed and presented numerous programs for professional associations, hospitals, and hospital associations on a wide range of topics including provider credentialing and privileging, medical staff meeting management, peer review, negligent credentialing, provider competency, and accreditation standards.
In her spare time, Ms. Matzka takes pleasure in spending time with her family, listening to music, singing with her church worship team, traveling, hiking, fishing, and other outdoor activities.
Table of Contents
Sample Letter Re: Documentation of TJC Requirements for Services Provided Through Contractual Agreement1
Credentials File Audit [Name] Hospital of TJC Requirements for MS.06.01.03 through MS.06.01.078
TELEPHONE INTERVIEW FORM MEDICAL STAFF/AHP STAFF AFFILIATION10
TELEPHONE INTERVIEW FORM PEER RECOMMENDATION11
Sample Bylaws Language12
Sample Letter Re: Documentation of TJC Requirements for Services Provided Through Contractual Agreement
Date
Facility Name
Facility Address
Dear Medical Services Professional:
As you are aware, our facility is contracting with your organization to provide telemedicine services.
Pursuant to our contract with your facility, we require the following in order to document compliance with the accreditation requirements of The Joint Commission:
· Completion of the attached chart documenting your facility’s compliance with the requirements specified in MS.06.01.03 through MS.06.01.07 (Alternate text for ambulatory care facility: Standard HR.02.01.03) and copies of all bylaws/policies/procedures in which these processes are documented; and
· A copy of the each provider’s privilege form from your facility;
· Documentation of current licensure and verification of such licensure for each provider
· Your facility’s process for updating the listing of providers who will be providing telemedicine services to our facility.
Thank you for your help.
Sincerely,
Medical Staff Coordinator
Kathy Matzka, CPMSM, CPCS – Understanding Telemedicine Credentialing Options
13
TJC Requirement
Place Where Documented
Comments
MS.06.01.03 The organization collects information regarding each practitioner’s current license status, training, experience, competence, and ability to perform the requested privilege.
The hospital credentials applicants using a clearly defined process
The credentialing process is approved by the governing body
The credentialing process is outlined in the medical staff bylaws
The hospital verifies that the practitioner requesting approval is the same practitioner identified in the credentialing documents by viewing one of the following:
· Current picture hospital ID card.
· Valid picture ID issued by a state or federal agency (e.g., drivers license or passport
The credentialing process requires that the hospital verifies in writing and from the primary source whenever feasible, or from CVO, the following information:
· current licensure at time of initial granting, renewal, and revision of privileges, and expiration.
· relevant training
· current competence
MS.06.01.05 - The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidenced-based process
All LIPs that provide care possess a current license, certification, or registration, as required by law and regulation
The hospital, based on recommendations by the organized medical staff and approval by the governing body, establishes criteria that determine a practitioner’s ability to provide patient care, treatment, and services within the scope of the privilege(s) requested. Evaluation of all of the following are included in the criteria:
· Current licensure and/or certification, as appropriate, verified with the primary source.
· The applicant’s specific relevant training, verified with the primary source.
· Evidence of physical ability to perform the requested privilege.
· Data from professional practice review by an organization(s) that currently privileges the applicant (if available).
· Peer and/or faculty recommendation.
· When renewing privileges, review of the practitioner’s performance within the hospital.
All of the criteria used are consistently evaluated for all practitioners holding that privilege
The hospital has a clearly defined procedure for processing applications for the granting, renewal, or revision of clinical privileges
The procedure for processing applications for the granting, renewal, or revision of clinical privileges is approved by the organized medical staff
An applicant submits a statement that no health problems exist that could affect his or her ability to perform the privileges requested. The applicant's ability to perform privileges requested must be evaluated. This evaluation is documented in the individual's credentials file.
The hospital queries the National Practitioner Data Bank (NPDB) when clinical privileges are initially granted, at the time of renewal of
privileges, and when a new privilege(s) is requested.
Peer recommendation includes written information regarding the practitioner’s current:
· Medical/Clinical knowledge.
· Technical and clinical skills.
· Clinical judgment.
· Interpersonal skills.
· Communication skills.
· - Professionalism.
Before recommending privileges, the organized medical staff also evaluates the following:
· Challenges to any licensure or registration.
· Voluntary and involuntary relinquishment of any license or registration.
· Voluntary and involuntary termination of medical staff membership.
· Voluntary and involuntary limitation, reduction, or loss of clinical privileges.
· Any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant.
· Documentation as to the applicant’s health status.
· Relevant practitioner-specific data as compared to aggregate data, when available.
· Morbidity and mortality data, when available.
The hospital has a process to determine whether there is sufficient clinical performance information to make a decision to grant, limit, or deny
the requested privilege.
Completed applications for privileges are acted on within the time period specified in the medical staff bylaws
Information regarding each practitioner’s scope of privileges is updated as changes in clinical privileges for each practitioner are made
MS.06.01.07 - The organized medical staff reviews and analyzes all relevant information regarding each requesting practitioner’s current licensure status, training, experience, current competence, and ability to perform the requested privilege
The information review and analysis process is clearly defined
The hospital, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be
considered in the decision to grant, limit, or deny a requested privilege
The hospital completes the credentialing and privileging decision process in a timely manner
The hospital’s privilege granting /denial criteria are consistently applied for each requesting practitioner
Decisions on membership and granting of privileges include criteria that are directly related to the quality of health care, treatment, and services.
If privileging criteria are used that are unrelated to quality of care, treatment, and services or professional competence, evidence exists that the impact of resulting decisions on the quality of care, treatment, and services is evaluated.
The governing body or delegated governing body committee has final authority for granting, renewing, or denying privileges
Privileges are granted for a period not to exceed two years
Chart for Contracted Agency to Document Compliance with TJC Requirements for MS.06.01.03 through MS.06.01.07
TJC Requirement
Standard Met
Comments
Yes
No
MS.06.01.03 The organization collects information regarding each practitioner’s current license status, training, experience, competence, and ability to perform the requested privilege.
The hospital credentials applicants using a clearly defined process
The credentialing process is approved by the governing body
The credentialing process is outlined in the medical staff bylaws
The hospital verifies that the practitioner requesting approval is the same practitioner identified in the credentialing documents by viewing one of the following:
· Current picture hospital ID card.
· Valid picture ID issued by a state or federal agency (e.g., drivers license or passport
The credentialing process requires that the hospital verifies in writing and from the primary source whenever feasible, or from CVO, the following information:
· current licensure at time of initial granting, renewal, and revision of privileges, and expiration
· relevant training
· current competence
MS.06.01.05 - The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidenced-based process
All LIPs that provide care possess a current license, certification, or registration, as required by law and regulation
The hospital, based on recommendations by the organized medical staff and approval by the governing body, establishes criteria that determine a practitioner’s ability to provide patient care, treatment, and services within the scope of the privilege(s) requested. Evaluation of all of the following are included in the criteria:
· Current licensure and/or certification, as appropriate, verified with the primary source.
· The applicant’s specific relevant training, verified with the primary source.
· Evidence of physical ability to perform the requested privilege.
· Data from professional practice review by an organization(s) that currently privileges the applicant (if available).
· Peer and/or faculty recommendation.
· When renewing privileges, review of the practitioner’s performance within the hospital.
All of the criteria used are consistently evaluated for all practitioners holding that privilege
The hospital has a clearly defined procedure for processing applications for the granting, renewal, or revision of clinical privileges
The procedure for processing applications for the granting, renewal, or revision of clinical privileges is approved by the organized medical staff
An applicant submits a statement that no health problems exist that could affect his or her ability to perform the privileges requested. The applicant's ability to perform privileges requested must be evaluated. This evaluation is documented in the individual's credentials file.
The hospital queries the National Practitioner Data Bank (NPDB) when clinical privileges are initially granted, at the time of renewal of privileges, and when a new privilege(s) is requested.
Peer recommendation includes written information regarding the practitioner’s current:
· Medical/Clinical knowledge.
· Technical and clinical skills.
· Clinical judgment.
· Interpersonal skills.
· Communication skills.
· Professionalism.
Before recommending privileges, the organized medical staff also evaluates the following:
· Challenges to any licensure or registration.
· Voluntary and involuntary relinquishment of any license or registration.
· Voluntary and involuntary termination of medical staff membership.
· Voluntary and involuntary limitation, reduction, or loss of clinical privileges.
· Any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant.
· Documentation as to the applicant’s health status.
· Relevant practitioner-specific data as compared to aggregate data, when available.
· Morbidity and mortality data, when available.
The hospital has a process to determine whether there is sufficient clinical performance information to make a decision to grant, limit, or deny the requested privilege.
Completed applications for privileges are acted on within the time period specified in the medical staff bylaws
Information regarding each practitioner’s scope of privileges is updated as changes in clinical privileges for each practitioner are made
MS.06.01.07 - The organized medical staff reviews and analyzes all relevant information regarding each requesting practitioner’s current licensure status, training, experience, current competence, and ability to perform the requested privilege
The information review and analysis process is clearly defined
The hospital, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a requested privilege
The hospital completes the credentialing and privileging decision process in a timely manner
The hospital’s privilege granting /denial criteria are consistently applied for each requesting practitioner
Decisions on membership and granting of privileges include criteria that are directly related to the quality of health care, treatment, and services.
If privileging criteria are used that are unrelated to quality of care, treatment, and services or professional competence, evidence exists that the impact of resulting decisions on the quality of care, treatment, and services is evaluated.
The governing body or delegated governing body committee has final authority for granting, renewing, or denying privileges
Privileges are granted for a period not to exceed two years
Chart for Audit of Documentation of TJC Requirements for MS.06.01.03 through MS.06.01.07
Items in bold represent auditable elements
Credentials File Audit [Name] Hospital of TJC Requirements for MS.06.01.03 through MS.06.01.07
Scoring: 1 = Element is present and in compliance, 0 = Element is not present or is not in compliance, N/A = not applicable
Element of Review
File 1
File 2
File 3
File 4
File 5
File 6
File 7
File 8
File 9
File 10
Ratio (#/#)
Practitioner Name
Application present, complete, signed
Peer References Received and appropriate
Documentation of applicant statement that no health problems exist that could affect his or her ability to perform the privileges requested and documentation of
ID verification present
NPDB Query
PSV Medical School
ECFMG verification (if applicable)
PSV of Fellowship present (if applicable)
PSV of Residency present
PSV of [your] state license
PSV of other state License(s)
PSV of state controlled substance license
PSV Board Certification
Current DEA Certificate present
Privileges
Privilege form present and appropriate to specialty
Form signed by applicant
Form completed correctly
Privileges evaluated and recommended by department
Privilege decision granted pursuant to bylaws including time frame for approval
There is consistent application of credentialing criteria as specified in bylaws
Before recommending privileges, the organized medical staff also evaluates
Challenges to any licensure or registration.
Voluntary and involuntary relinquishment of any license or registration.
Voluntary and involuntary termination of medical staff membership.
Voluntary and involuntary limitation, reduction, or loss of clinical privileges.
Any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant.
Documentation as to the applicant’s health status.
Relevant practitioner-specific data as compared to aggregate data, when available.
Morbidity and mortality data, when available.
Information regarding the practitioner’s scope of privileges is updated as changes in clinical privileges for each practitioner are made
Privileges do not exceed two years
Date of Audit: __________________________________________________________ Audit Performed by: _____________________________________________________
TELEPHONE INTERVIEW FORM MEDICAL STAFF/AHP STAFF AFFILIATION
Name of Provider ________________________________________________________________
Name of Hospital/Facility __________________________________________________________
Name/Title of Person Providing Information___________________________________________
Date(s) of Affiliation From_______________________ To_______________________
If the answer to any question is “yes”, acquire specific information.
YES NO
1.Were (are) there any concerns regarding
A.Clinical/technical skills|_||_|
B.Competency to perform privileges requested|_||_|
C.Mental/physical health as it relates to privileges requested.|_||_|
2.Were the applicant’s privileges ever voluntarily or involuntarily|_||_|
reduced, suspended, terminated or restricted in any way?
3.Did the applicant’s resign privileges or appointment in lieu of |_||_|
disciplinary action?
3. To your knowledge how does he/she get along with
Nursing Staff____________________________________________________
Patients________________________________________________________
Physicians______________________________________________________
Is there anything else we need to know about this provider? Use back of page, if necessary.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
__________________________________________ _______________________
Name and title of person conducting interview Date
TELEPHONE INTERVIEW FORM PEER RECOMMENDATION
Name of Provider ________________________________________________________________
Name/Title of Person Providing Information___________________________________________
Relationship to Applicant__________________________________________________________
Number of Years Known __________________________________________________________
Please comment on the following items:
Clinical Judgement___________________________________________________________
__________________________________________________________________________
Clinical/technical skills________________________________________________________
__________________________________________________________________________
Competency to perform privileges requested______________________________________
_________________________________________________________________________
Mental/physical health as it relates to privileges requested.______________________
____________________________________________________________________
Use of hospital resources________________________________________________
____________________________________________________________________
Interpersonal and Communication Skills: How does he/she communicate and get along with
Nursing Staff____________________________________________________
Patients________________________________________________________
Physicians______________________________________________________
Professionalism: Does he/she demonstrate respect, compassion, and integrity?_____
____________________________________________________________________
Is there anything else we need to know about this provider?
_______________________________________________________________________________________________
__________________________________________ _______________________
Name and title of person conducting interview Date
Sample Bylaws Language
TELEMEDICINE
Scope of Privileges
The Medical Staff shall make recommendations to the Board of Trustees regarding which clinical services are appropriately delivered through the medium of telemedicine, and the scope of such services. Clinical services offered through this means shall be provided consistent with commonly accepted quality standards.
Telemedicine Physicians
Any physician or practitioner who prescribes, renders a diagnosis, provides radiologic interpretation, or otherwise provides clinical treatment from a distance via electronic communications, must be credentialed and privileged through the Medical Staff pursuant to the credentialing and privileging procedures described in this section, as applicable.
(1)When the Hospital is not a party to a written agreement with a distant-site Medicare [Joint Commission] -participating hospital or distant-site entity containing all of the requirements of the CMS Hospital Conditions of Participation [and Joint Commission standards] related to distant-site telemedicine credentialing, the telemedicine physician must be credentialed and privileged through the Medical Staff pursuant to the general credentialing and privileging procedures described in these Medical Staff Bylaws. Recognizing that telemedicine physicians may be privileged at many healthcare facilities and entities, the Hospital shall conduct the primary verification procedures for an adequate number of hospitals, health care organizations and/or practice settings with whom the telemedicine physician is or has previously been affiliated in order to ensure current competency. In order to assist in this credentialing and privileging process, the Hospital may request information from the telemedicine physician’s primary practice site to assist in evaluation of current competency. The Hospital may also accept primary source verification of credentialing information from the physician’s primary practice site or the telemedicine entity to supplement its own primary source verification.
(2)When the Hospital is a party to a written agreement with a distant-site Medicare [Joint Commission] -participating hospital or distant-site entity containing all of the requirements of the CMS Hospital Conditions of Participation [and Joint Commission standards] related to telemedicine credentialing and privileging, the Board has the option to have the Medical Staff rely upon (i) the telemedicine physician’s credentialing and privileging information from a distant-site Medicare [Joint Commission] -participating hospital or distant-site entity and (ii) the credentialing and privileging decisions of a distant-site Medicare [Joint Commission] participating hospital or distant-site entity related to the telemedicine physician. However, the Hospital will remain responsible for complying with applicable state regulations regarding the credentialing and privileging of practitioners; and performing the primary source verification of medical licensure, professional liability insurance, Medicare/Medicaid eligibility/exclusions, and query of the National Practitioner Data Bank.
For the purposes of this Section, the term “distant-site entity” shall mean an entity that: (1) provides telemedicine services; (2) is not a Medicare [Joint Commission] -participating hospital; and (3) provides contracted services in a manner that enables the hospital to meet all applicable CMS Hospital Conditions of Participation [and Joint Commission standards] related to the credentialing and privileging of physicians and contracted services. For the purposes of this Section, the term “distant-site hospital” shall mean a Medicare [Joint Commission] -participating hospital that provides telemedicine services.
