Privileging by Proxy

Privileging by Proxy

When The Joint Commission introduced the concept of “privileging by proxy” associated with their telemedicine standards, many organizations sighed with relief. However, some organizations are gasping with shock after receiving a Condition-level finding from the Centers for Medicare and Medicaid Services (CMS). In a recent discussion with sources at CMS, Compass Group has discovered that The Joint Commission’s standards are not consistent with the expectations for credentialing and privileging provided by CMS, and this must be addressed prior to Joint Commission’s deemed status recertification. This could mean that The Joint Commission’s standards might remain in conflict with CMS for some time, leaving organizations at risk for Condition-level findings and potentially, Medicare Termination.

Standards MS.4.120 & MS.4.130 outline expectations for telemedicine and introduce the concept of “privileging by proxy.” These standards are largely unchanged for 2009. In a recent conversation with David Eddinger, Technical Director Hospital Survey and Certification, CMS – Division of Acute Care Services, based in Baltimore, MD, the following principles were outlined:

  • Hospitals remain at risk for a Condition-level deficiency if they comply with the Joint Commission process outlined in MS.4.120 & MS.4.130 Telemedicine, accepting “privileging by proxy.”
  • Condition-level deficiencies can lead to 90-Day Termination Procedures if found during CMS surveys.
  • The basis for this violation is that the organization itself has not conducted its own individual evaluation of the practitioner in question, using the hospital’s own privileging process (that adheres to CMS rules). Rather, the hospital has accepted the privileging decision of another organization.
Now What?

The Joint Commission standards are not likely to change for 2008 and early 2009. According to Cpt. Eddinger, The Joint Commission is aware of the conflict presented by its interpretation and will have to correct the inconsistency during its deemed status reapplication process. Meanwhile, organizations will have to rely upon their own resources to assure compliance with both sets of expectations.

The logistics of credentialing individuals that do not practice “under the roof” are understandably challenging. However, each hospital will be held responsible for following its credentialing and privileging process for all individuals in its organization, whether they practice “in real life” or through a telemedicine link. To assure compliance, Compass Group recommends that organizations take steps to assure the following:>

  • Review the bylaws, rules, and regulations for compliance with the CMS Conditions of Participation based on the April 2008 revisions.
  • Evaluate the mechanisms used to credential telemedicine practitioners. Information from other facilities can be, and should be, included in the information used during the privileging process, but the privileging decision of another organization should not be used as the basis for privileging the individual at your organization.
  • Discuss the differences in the approach between Joint Commission and CMS, and coach Medical Staff leaders to avoid reference to “privileging by proxy” in front of CMS/State surveyors.
Figuring Out The Joint Commission and CMS Differences

This is only one example of how the subtle differences between Joint Commission and CMS standards can place your organization at risk during a validation or complaint survey. Given the pressure and public scrutiny that CMS currently faces in assuring high quality care, surveys will likely continue to get tougher over time. Your organization’s knowledge of the CMS standards and survey process can mean the difference between celebration and decertification.

Compass is uniquely positioned to offer a combined approach to Joint Commission and CMS compliance, balancing the demands of both agencies and guiding organizations to comply with standards in the most efficient way possible. Compass Group’s proven success in reversing Medicare decertification, and Joint Commission Preliminary Denial of Accreditation is but one aspect of our ample experience. Compass moves beyond simple interpretation of standards into realistic problem solving.

If you are considering looking for resources for ongoing compliance for Joint Commission and CMS compliance, consider the services of Compass. The Compass Forum audio conference series provides information on each Joint Commission and CMS chapter every year, addressing the latest updates and common solutions. Mock surveys and focused consultations assist in assessing readiness for both surveys, with each visit customized to the organization’s needs.