On February 23, 2009, The Center for Telehealth and E-Health Law (CTel) held its February Washington Live Brown Bag luncheon. Seminar participants heard from three panelists on the topic of physician credentialing for telehealth services, including Dr. Karen S. Rheuban, Professor of Pediatrics and Medical Director of the Office of Telemedicine at the University of Virginia; Geneva Harris, of the University of California-Davis and the California Hospital Association’s Joint Committee on Accreditation and License; and John Blum, Professor of Law at the Loyola University Chicago School of Law and a faculty member of the Beazley Institute for Health Law and Policy.
All three speakers have extensive and diverse experience in the area of credentialing, which has become an increasingly important issue for those in the telehealth arena. The Joint Commission (JC) has issued guidelines permitting one of its accredited facilities to recognize the credentialing process of another accredited facility, a process also known as credentialing by proxy. However, the Centers for Medicare and Medicaid (CMS) require that their own Conditions of Participation must be followed to credential physicians at each remote telehealth site—and as all three panelists noted, this can be highly inefficient.
The process of credentialing, explained Harris, is a lengthy and costly one for hospitals. She outlined the multiple steps that typically go into it, beginning with a provider’s application, continuing with review by several different committees at the facility and the collection of peer references and records for the provider from various sources, which then must be verified. Finally, the facility’s governing body will delineate the provider’s privileges.
Ultimately, though, the process comes at a high cost—as Harris estimated, approximately $500 per physician when costs like fees to the National Practitioner Databank and fees for obtaining references are factored in.
Additionally, every two years, physicians must be re-credentialed, with their clinical competency being assessed. Harris emphasized the importance of credentialing as far as patient safety is concerned, but pointed to the strain that it puts on facilities, particularly smaller ones with limited staff to devote to the credentialing process. She noted that when it comes to telemedicine services, credentialing could be greatly streamlined; in particular, if a provider’s home hospital were allowed to act as the credentialer, those involved in the process could avoid costly duplication of their efforts.
Other issues that the panel’s speakers raised included the impact that the lack of ability to credential by proxy could have on smaller health facilities—in particular, rural clinics and prisons. As Dr. Rheuban stated, “The areas with the greatest need are being negatively affected,” with providers often unable to deliver much-needed services via telehealth, due to CMS’s restrictive credentialing rules. CMS, she noted, should adopt the JC’s standards. Blum agreed, saying that the rules of the JC were “optimal” and would help to reduce the bureaucratic red tape involved in the credentialing process.
During the question-and-answer session, the focus turned to the legislative arena, and what overtures, if any, were being made to policymakers. Dr. Rheuban, who noted that her district’s House Member is circulating a letter among his colleagues, also spoke of the frustration she often feels at what she called the “misalignment” of the various federal agencies—including CMS, the Department of Agriculture, and the Federal Communications Commission—that play a role in telehealth programs, noting that the failure of agencies to communicate often leads to “roadblocks that tie our hands.” She also pointed to the need to educate the future Health and Human Services Secretary about the needs of the telehealth community. All three panelists were hopeful that the appointment of Dr. Mary Wakefield as Health Resources and Services Administration Administrator would prove to be a positive development for those in telemedicine, as Dr. Wakefield, who is originally from North Dakota, is familiar with the importance of telehealth, particularly when it comes to fulfilling the needs of rural areas.
An additional question focused on CMS and JC; if CMS were to change their process for credentialing, the participant asked, would facilities have to follow the rules of the JC or those of CMS? Blum explained that “CMS trumps JC.” Another participant asked the panelists what they saw as the logical first step in ultimately “streamlining” the process of credentialing. Dr. Rheuban reiterated the need for “a champion at HHS who understands” the process, while Blum noted that ultimately, it will be up to CMS “to create a favorable climate.”
As of right now, CMS has yet to issue an actual directive regarding proxy credentialing. Currently, CTel is working to develop an assessment for providers about the impact of CMS’s credentialing rules on the delivery of telehealth services. Ultimately, CTel hopes to share information from the study with CMS.
Click here to compete the CTeL Assessment on Credentialing
