Guidance on the Joint Commission’s Temporary and Disaster Privileging Policies

As COVID-19 increases the demand for healthcare personnel, hospitals are activating their emergency plans to quickly onboard practitioners to meet patient demand. In the current national emergency, the Secretary of Health and Human Services has modified certain CMS requirements, including Conditions of Participation, by invoking 1135 Waivers. This enables hospitals to amend their credentialing and onboarding processes to quickly accommodate more practitioners. The Joint Commission provides the following guidance on temporary and disaster privileging for such emergencies through Medical Staff Chapter, Standard MS.06.01.13.

Temporary Privileges
Per Medical Staff Chapter, Standard MS.06.01.13, Joint Commission-accredited hospitals may grant temporary privileges to quickly increase its number of privileged practitioners when the current number of privileged personnel cannot meet patient volume.

Disaster Privileges
The Joint Commission refers to Emergency Management Chapter, Standard EM.02.02.13 protocol to enable its accredited hospitals to provide temporary privileges once their governing body or hospital board activates their emergency operations plans and need to increase privileged personnel to meet patient demand.  According to Standard EM.02.02.13, EP2 refers to the hospital’s medical staff bylaws to identify the personnel responsible for issuing disaster privileges. In designated emergencies, accredited hospitals may also privilege volunteer licensed independent practitioners.

Typically, those who are licensed independent practitioners in professions that a hospital medical staff recognizes and privileges can practice without supervision. MSPs should refer to their hospital bylaws and state licensure laws to confirm supervision requirements.  State licensure law will also provide guidance on practitioner supervision requirements.

Through Standard EM.02.02.15, the Joint Commission also enables its accredited hospitals to privilege volunteer practitioners who are not licensed independent practitioners, but required to have a license, certification, or registration.

Credentialing and Privileging for Temporary Privileges
The Joint Commission requires its accredited hospitals to verify a practitioner’s current license and competence, as well as document the current need for granting temporary privileges via the MSO Chief of Staff or designee recommendation, in the practitioner’s credentialing file.  MSPs should also query the NPDB before granting temporary privileges.

All hospitals that provide temporary or disaster-related privileges must have protocol for overseeing these practitioners. The Joint Commission provides more logistical guidance on credentialing practitioners during disasters, as well as overseeing practitioners with temporary or disaster-related privileges.

Additional COVID-19 Hospital Resources:
• The Joint Commission’s COVID-19 Page.
• NAMSS
• American Hospital Association
• Arent Fox

Member Telemedicine Credentialing Resource: NAMSS-ATA Credentialing by Proxy Guidebook

The sudden reliance on telemedicine amid the COVID-19 pandemic prompts many questions on credentialing practitioners for services not originally considered for telemedicine. The resulting questions often fall to MSPs, who are essential to ensuring and streamlining practitioner access during this pandemic. As such, NAMSS would like to remind its members that the NAMSS/ATA (American Telemedicine Association) Credentialing by Proxy Guidebook is available for this very purpose.

In August 2019, NAMSS introduced the NAMSS-ATA CBP Guidebook, which provides guidance on proxy credentialing for practitioners providing telemedicine. The Guidebook is a result of a multi-year collaborative effort between NAMSS and ATA members that originated from the need to develop a process to more efficiently facilitate proxy credentialing—and to establish standards and guidance for the CBP process. 

The CBP Guidebook also includes an overview of credentialing practitioners providing telemedicine, laws and regulations around telemedicine credentialing, a set of guidelines institutions can use to create CBP programs, and potential solutions to obstacles institutions may encounter when with implementing or facilitating a CBP process. The CBP Guidebook is also applicable for implementing modified credentialing and privileging requirements for additional medical professionals to respond in emergencies such as pandemics.

NAMSS is monitoring the evolving COVID-19 pandemic and is committed to serving you and the medical service profession. Useful resources and information can be viewed here. 

A Guide to Emergency Credentialing and Privileging for Healthcare Staff during COVID-19 Pandemic

The COVID-19 pandemic implements non-pharmaceutical interventions daily and hospitals and medical professionals are preparing for a large wave of coronavirus cases. Medical professionals and hospitals are eliminating obstacles to provide medical care for COVID-19 patients as quickly as possible such as waiving the need to credential and privilege additional medical professionals in events of emergency or disaster. Here are some key takeaways and resources from recent events:

On March 13, 2020, the President declared a State of National Emergency  Key takeaways:

1. Grants the Secretary of Health and Human Services Emergency Authority to temporarily waive Medicare and Medicaid program requirements and HIPAA.
2. The Secretary of HHS is granted power to waive “Conditions of Participation or other certification requirements” and to waive requirements that medical professionals be licensed in the State they practice in.
3.  The declaration exempts healthcare practitioners who do not have one or more requirements from sanctions or penalties.

Read more here for additional COVID-19 updates from HHS.

California Governor Newsom declared a State of Emergency for California. Key takeaways:  

1. Permits any out-of-state medical professionals to provide services with respect to licensing and certification as described in the Multi-state Emergency Management Assistance Compact.
2. The Medical Board of California is granted permission to re-activate expired licenses of physicians if the license expired within the past five years using an accelerated approval process.

The Joint Commission Emergency Management Standards outline hospital requirements in the event of emergency or disaster. Key takeaways include:

1. Under the Standards, a hospital in the event of disaster “may use a modified credentialing and privileging process on a case-by-case basis for eligible volunteer practitioners” if the hospital implements its Emergency Operations Plan and there is a need for additional medical assistance.
2. These disaster privileges may be granted only if the volunteer practitioner presents proof of current licensure, privileging at another medical facility, participation in a state of federal response organization, or governmental approval.
3. A primary source of the hospital may verify the abilities of a volunteer practitioner to act as a licensed independent practitioner during a disaster within 72 hours and the hospital must have an oversight mechanism in writing.

Read more here

NAMSS is monitoring the evolving COVID-19 pandemic and is committed to serving you and the medical service profession. Useful resources and information can be viewed here. 

COVID-19 Updates

CMS waives state licensure requirements for physicians and recommends hospitals to suspend elective procedures

Becker’s Hospital Review reports that on March 18, CMS waived licensure requirements for physicians and other healthcare professionals allowing them to provide services in states where they are not formally licensed. With the number of U.S. cases now surpassing 7,000, CMS has recommended that all hospitals comply with the American College of Surgeons’ guidance to cancel elective procedures. The Pentagon has immediately taken action and provided the first million of five million respirator masks to federal health agencies. In addition to respirator masks, 2,000 ventilators will be provided in days to come. In the wake of urgency, President Trump has asked Congress to pass a stimulus package that would include $250 billion to Americans affected by this pandemic. HIPAA penalties will not be enforced, allowing healthcare practitioners to communicate with patients by phone.

FSMB is keeping an updated chart of the states waiving licensure requirements and renewals in the wake of the COVID-19 virus.

The Joint Commission Suspends Regular Surveys

The Joint Commission has suspended regular accreditation and certification surveys beginning March 16, 2020 to enable healthcare organizations to respond to COVID-19. The Joint Commission will administer a small number of situational surveys and report on them soon. The Commission will extend healthcare organizations’ accreditation without penalty if the renewal date passes while the surveys are suspended.

Read more from The Joint Commission

CMS Expands Medicare Telehealth Services to Fight COVID-19

The Trump Administration announced the expansion of telehealth services for Medicare beneficiaries to combat the COVID-19 virus. As of March 6, Medicare-funded healthcare professionals and hospitals can provide temporary telehealth services to beneficiaries. Telehealth visits will reflect the same reimbursement rate as in-person visits. These services will also apply to nursing homes and outpatient departments. To facilitate telehealth services, HHS will temporarily suspend some HIPAA requirements, so healthcare practitioners can use their personal devices for telehealth services. Since state Medicaid agencies do not require federal permission, the Administration has requested that states implement telehealth services as well. CMS released a Telehealth Fact Sheet and FAQ Sheet providing guidance for healthcare providers on the telehealth waiver in the Supplemental Appropriations package. Officials hope that the expanding telehealth services will slow the spread of the coronavirus.

Read more here

NAMSS is monitoring the evolving COVID-19 pandemic and is committed to serving you and the medical service profession. Useful resources and information can be viewed here. 

ABPS Acknowledges Contributions of MSPs to Healthcare Leadership in U.S.

The American Board of Physician Specialties joins the U.S. healthcare community in acknowledging the importance of medical service professionals (MSP) in commemorating the National Medical Staff Services Awareness Week. In 1992, President George Bush recognized the first week in November as National Medical Staff Services Awareness Week and since then, medical facilities and government agencies have celebrated the importance of medical services professionals.  ABPS promotes the importance of MSPs in verifying physicians’ credentials to help ensure the highest quality of medical care is delivered.

MSPs continue to evolve as they now have more roles to fill than ever before. MSPs performed more administrative duties in the past, but their role has developed to have more responsibilities such as working with gap analysis, primary source verification, telehealth credentialing, allied-health practitioner credentialing, and reconciling a manual process with new technologies. The medical industry has switched to electronic record keeping, which has reduced the number of workers in an organizations managed services office. Due to the lack of workers, MSPs are overloaded with a number of duties such as coordinating medical staff onboarding, managing credentialing, and acting as the liaison between hospitals and staff.

There is more demand for higher education and training among MSPs because of how complex the job has become. It is important to recognize the hard work MSPs perform on a daily basis as their role continues to become more challenging. View the article here.

Roxanne Chamberlain Attended the AHLA Annual Meeting

In June, Roxanne Chamberlain, MBA, FACHE, FMSP, CPMSM, CPCS, Senior Director of Medical Staff Services at Baystate Health, Inc. and 2019 NAMSS President-Elect, attended the American Healthcare Lawyers Association (AHLA) Annual Meeting in Boston, MA. Health law professionals attend the meeting each year for the most current information and analysis on a variety of legal issues affecting the healthcare industry. The annual meeting included thoughtful, practical, solution-oriented sessions, luncheons, and networking events.

John P. Ryan, President and Managing Partner, Hall Render Killian Health & Lyman PC and Heather Brace, Senior VP and Chief People Officer, Intermountain Healthcare, delivered the Meeting’s keynote address, The Future of the Health Care Workforce. The keynote session focused on the leading influences affecting the healthcare industry and their potential legal challenges. Experienced health law professionals facilitated breakout sessions on practice-management topics, top-physician compensation risk areas, understanding and addressing conflicts of interest at non-profit organizations, and coping with the mystery and reality of artificial intelligence (AI) in healthcare.

Roxanne attended many of the Meeting’s AI learning sessions, which included AI liability, and how it could affect the standard of care in medical malpractice cases, as well as how AI bedside assistance will simplify doctor and nurse workloads. Roxanne also attended sessions about healthcare policy and hazard prevention where she learned that efforts to reduce healthcare costs have made little progress, as states continue to file lawsuits regarding the Affordable Care Act. Additional sessions surrounded topics on practitioner conscious clauses and hospital-acquired infection reduction rates in 2018-2019.

Drug price transparency was another popular topic, as well as how states and the federal government are combating rising drug prices. Nine states have passed drug-price transparency laws and seven other states are in the process of passing legislation.

Roxanne also attended sessions related to healthcare data and telehealth and noted that the U.S. Chamber of Commerce continues to call for a federal data privacy law due to inconsistent state laws and the number of data breeches. The healthcare sector continues to embrace digital invocations as consumer demand increases. Healthcare law professionals recommended that hospitals take an interdisciplinary team approach to implementing telehealth proposals and their legal staffs should have multi-faceted telehealth competencies to handle with regulatory issues.

As NAMSS liaison to AHLA, Roxanne stands by as a resource to the membership and is available to answer additional questions or provide additional information about AHLA.

A Conversation with Dr. Peter Hill, 2019 CVO Excellence Symposium Keynote Speaker

The CVO Excellence Symposium, the first event designed for MSPs who work in credentials verification organizations (CVO), is a two-day event focusing on the crucial discussions related to the state of the CVO, exploring topics such as staffing models, legal and regulatory issues, technology and innovation, and streamlining processes from the top-down. NAMSS recently sat down with Dr. Peter Hill, the Symposium’s keynote speaker, who serves as the Senior Vice President of Medical Affairs for the Johns Hopkins Health System and Vice President of Medical Affairs/Chief Medical Officer for the Johns Hopkins Hospital, to discuss what he’ll cover in his keynote presentation:

1. Can you give a small preview of what you’ll be covering in your keynote presentation at the NAMSS CVO Symposium?

·        How health systems are embracing the ongoing challenges in healthcare.

·        Impact of telehealth services and the impact on credentialing these practitioners within a health system

·        Credentialing the “Virtual doctor/practitioner” and its impact within patient safety and quality

2. What are some of the primary challenges you’re looking to address in your keynote?

·        Developing delineation of privileges, credentialing criteria, and meaningful FPPE/OPPE for the use of artificial intelligence and the virtual doctor.

·        Onboarding practitioners in a timely manner within the hospitals and provider enrollment.  It is extremely important in today’s market that practitioners are “billable” on their effective start date.

·        Revenue cycle management begins with credentialing.

3. Why is the NAMSS CVO Symposium important for MSPs to attend?

The CVO Symposium is important for MSPs to attend as it provides focused knowledge on best practices utilized within various health system CVOs.  We learn from each other.  It is an opportunity to ask questions, network, and collaborate with one another or strategize to move organizations forward and provide safe care to our patients. 

4. Are you seeing a greater need for programming specific to CVOs in the larger MSP community?

Yes, as more and more health systems develop central credentialing or central verification offices, it is important for MSPs to learn from one another on various aspects of moving the profession, their specific organization and healthcare forward.  We are all working together to navigate the ever-changing world of health care.  By sharing knowledge with one another, we can all learn to become more lean and efficient while safe guarding our patients.

5. What do you hope MSPs will take away from your keynote address?

First and foremost, that we are all in this together.   Healthcare is continuing to change and MSPs are at the forefront of patient safety.  With the emergence of digital healthcare and ongoing issues with “access,” I hope MSPs take away that they have a voice and opportunity to make a difference in their health system by working collaboratively with their leadership and feel empowered to share their innovative ideas.  There is never a dull day working in healthcare and by networking and collaborating with one another, we can make a difference.

The 2019 NAMSS CVO Excellence Symposium takes place October 19-20 at the Philadelphia Marriot Downtown in Philadelphia, PA. Register today.