CMS SOM App. W, Tag C-0874

services are furnished to the CAH’s patients through an agreement with a distant-site telemedicine entity, the agreement is written and specifies that the distant-site

telemedicine entity is a contractor of services to the CAH and as such, in accordance

with §485.635(c)(4)(ii), furnishes the contracted services in a manner that enables

the CAH to comply with all applicable conditions of participation for the contracted

services, including, but not limited to, the requirements in this section with regard to

its physicians and practitioners providing telemedicine services.

§485.616(c)(4) When telemedicine services are furnished to the CAH’s patients

through an agreement with a distant-site telemedicine entity, the CAH’s governing

body or responsible individual may choose to rely upon the credentialing and

privileging decisions made by the governing body of the distant-site telemedicine

entity regarding individual distant-site physicians or practitioners. The CAH’s

governing body or responsible individual must ensure, through its written

agreement with the distant-site telemedicine entity, that the following provisions are

met:

(i) The distant-site telemedicine entity’s medical staff

credentialing and privileging process and standards at least

meet the standards at (c)(1)(i) through (c)(1)(vii).

(ii) The individual distant-site physician or practitioner is

privileged at the distant-site telemedicine entity providing the

telemedicine services, which provides a current list to the CAH

of the distant-site physician’s or practitioner’s privileges at the

distant-site telemedicine entity.

(iii) The individual distant-site physician or practitioner holds a

license issued or recognized by the State in which the CAH

whose patients are receiving the telemedicine services is

located.

(iv) With respect to a distant-site physician or practitioner, who

holds current privileges at the CAH whose patients are

receiving the telemedicine services, the CAH has evidence of an

internal review of the distant-site physician’s or practitioner’s

performance of these privileges and sends the distant-site

telemedicine entity such information for use in periodic

appraisal of the distant-site physician or practitioner. At a

minimum, this information must include all adverse events

that result from the telemedicine services provided by the

distant-site physician or practitioner to the CAH’s patients and

all complaints the CAH has received about the distant-site

physician or practitioner.

Interpretive Guidelines §485.616(c)(3)&(4)

For the purposes of this rule, a distant-site telemedicine entity is defined as an entity that

-- (1) provides telemedicine services; (2) is not a Medicare-participating hospital; and (3)

provides contracted services in a manner that enables a CAH using its services to meet all

applicable CoPs, particularly those requirements related to the credentialing and

privileging of physicians and practitioners providing telemedicine services to the patients

of a CAH. A distant-site telemedicine entity would include a distant-site hospital that

does not participate in the Medicare program that is providing telemedicine services to a

Medicare-participating CAH. (See 76 FR 25553, May 5, 2011)

A CAH may have an agreement with a distant-site telemedicine entity for the provision

of telemedicine services to the CAH’s patients by physicians or practitioners granted

privileges by the distant-site telemedicine entity.

If a CAH enters into an agreement for telemedicine services with a distant-site

telemedicine entity, the agreement must be in writing. Furthermore, the written

agreement must specify that under the agreement the distant-site telemedicine entity is a

contractor providing services to the CAH, and that, in accordance with the requirements

of §485.635(c)(4)(ii), the distant-site telemedicine entity furnishes its telemedicine

services in a manner that enables the CAH to comply with all applicable CAH Conditions

of Participation (CoPs), including, but not limited to, the specific requirements governing

telemedicine services. 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 CAH’s governing body (or the individual responsible for the CAH if it has no

governing body) has the option, when considering granting privileges to telemedicine

physicians and practitioners, to rely upon the credentialing and privileging decisions of

the distant-site telemedicine entity for these physicians and practitioners. In order to

exercise this alternative credentialing and privileging option, the CAH’s governing body

must ensure through its written agreement with the distant-site telemedicine entity that all

of the following requirements are included in the agreement and that the contractor

fulfills these requirements:

• The distant-site telemedicine entity’s medical staff credentialing and privileging

process and standards at least meets the standards at §485.616(c)(1)(i) through

(c)(1)(vii). In other words, the distant-site telemedicine entity must at a minimum:

• Determine, in accordance with State law, which categories of practitioners are

eligible candidates for medical staff privileges or membership at the telemedicine

entity;

• Appoint members and grant medical staff privileges after considering the

recommendations of the existing members of its medical staff;

• Assure that its medical staff has bylaws;

• Approve its medical staff‘s bylaws and other medical staff rules and regulations;

• Ensure that the medical staff is accountable to the distant-site telemedicine

entity’s governing body for the quality of care provided to patients;

• Ensure the criteria for granting distant-site telemedicine medical staff

membership/privileges to an individual are the individual’s character,

competence, training, experience, and judgment; and

• Ensure that under no circumstances is the accordance of medical staff

membership or privileges dependent solely upon certification, fellowship or

membership in a specialty body or society.

• The distant-site telemedicine entity provides to the CAH a list of all its physicians and

practitioners covered by the agreement, including their privileges at the distant-site

telemedicine entity. The list may not include any physician or practitioner who does

not hold privileges at the distant-site telemedicine entity. The list must be current, so

the agreement must address how the distant-site telemedicine entity will keep the list

current;

• Each physician or practitioner who provides telemedicine services to the CAH’s

patients under the agreement holds a license issued or recognized by the State where

the CAH is located. States may have varying requirements as to whether they will

recognize an out-of-state license for purposes of practicing within their State, and

they may also vary as to whether they establish different standards for telemedicine

services. The licensure requirements governing in the State where the hospital whose

patients are receiving the telemedicine services is located must be satisfied, whatever

they may be; and

• The CAH reviews the performance of the physicians and practitioners providing

telemedicine services to its patients and provides a written review to the distant-site

telemedicine entity for the latter’s use in its periodic appraisal of each physician and

practitioner providing telemedicine services under the agreement. At a minimum, the

CAH must review and send information to the distant-site telemedicine entity on all

adverse events that result from a physician’s or practitioner’s provision of

telemedicine services and on all complaints the CAH has received about a

telemedicine physician or practitioner.

If the CAH’s governing body or responsible individual does not rely on the privileging

decisions of the distant-site telemedicine entity, then it must for each practitioner

providing telemedicine services under an agreement follow the CAH’s standard process

for review of credentials and granting of privileges to physicians and practitioners.

Survey Procedures §485.616(c)(3)&(4)

• Ask the CAH’s leadership whether it uses telemedicine services. If yes,

• Ask to see a copy of the written agreement(s) with the distant-site telemedicine

entity(ies). Does each agreement explicitly state that the distant-site telemedicine

entity will provide telemedicine services in a manner that enables the CAH to

comply with all applicable CoPs?

• Does the CAH have documentation indicating that it granted privileges to each

telemedicine physician and practitioner?

• Does the documentation indicate that the CAH’s governing body or responsible

individual made the privileging decision based on the privileging decisions of the

distant-site telemedicine entity? If yes:

• Does the written agreement with the distant-site telemedicine entity address

the required elements concerning the distant-site telemedicine entity’s

utilization of a medical staff credentialing and privileging process that meets

the requirements of the hospital CoPs, licensure of telemedicine physicians

and practitioners, current list of telemedicine physicians and practitioners with

privileges at the distant-site telemedicine entity, and written review by the

CAH of the telemedicine physicians’ and practitioners’ services?

• Is there a list provided by the distant-site telemedicine entity of the

telemedicine physicians and practitioners covered by the agreement, including

their privileges and pertinent licensure information?

• Is there evidence that the CAH reviews the services provided by the

telemedicine physicians and practitioners, including any adverse events and

complaints, and provides written feedback to the distant-site telemedicine

entity?

• Ask the CAH how it verifies that the telemedicine entity fulfills the terms of the

agreement with respect to its credentialing and privileging process and otherwise

assures that services are provided in a manner that enables the CAH to meet all

applicable CAH requirements? (Surveyors do not attempt to independently verify

whether or not the distant-site telemedicine entity’s credentialing and privileging

process fulfills the regulatory requirements. Surveyors focus only on what actions

the CAH takes to ensure that the distant-site telemedicine entity complies with the

terms of the agreement.)