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The Joint Commission’s Improved Accreditation Rules

April 28, 2021

The Joint Commission recently revised its rules for accreditation, specifically credentialing and privileging of telemedicine practitioners in hospitals. The latest rule change applies to Standard MS.13.01.01 for telemedicine service providers. Under the revised guidelines, the distant site telemedicine entity must be accredited with either The Joint Commission or enrolled in the Medicare program. Before this revision, both the originating site hospital and the distant site entity had to be accredited with The Joint Commission. This change will benefit both originating sites and distant sites, increasing efficiency and saving money by streamlining the credentialing process.

Credentialing by Proxy 

The practice of allowing an originating hospital site to rely on the privileging and credentialing decisions made by a distant site is known as credentialing by proxy. The Medicare Conditions of Participation require physicians and other healthcare practitioners to undergo a credentialing process that ensures their qualifications are current and valid before they are permitted to provide healthcare services. Practitioners who provide services via telemedicine are also required to undergo credentialing but performing the full credentialing process as required can be a challenge for originating hospitals that may lack the necessary resources. Credentialing by proxy allows originating site providers to rely on distant sites for credentialing information so they can streamline the complex credentialing process, meet Medicare and Medicaid credentialing standards, and allow increased access to medical services.

Credentialing by Proxy Can Occur in Several Ways: 

  1. Full accreditation through the originating site
  2. The originating site can use credentialing information from the distant site if the distant site is fully accredited in the state where treatment is provided and if the distant site is a Joint Commission-accredited organization or a Medicare-enrolled entity
  3. The originating site may use credentialing information from the distant site for privileging under the following conditions:
  • The distant site is accredited by the Joint Commission or enrolled in the Medicare program
  • The practitioner is privileged by the distant site to provide services at the originating site
  • The distant site gives the originating site an updated list of licensed independent practitioners’ privileges
  • The originating site reviews the practitioner’s ability to give quality care according to the privileges granted and shares this information with the distant site

The distant site has a license issued by the state where services are performed. Distant-site hospitals evaluate the quality of care for critical access hospitals providing telemedicine services. Distant-site hospitals providing telemedicine services may, in turn, be evaluated for quality of care by a member hospital or other qualified entity identified by the state health plan. Although some organizations complete credentialing themselves, The Joint Commission permits credentials verification organizations (CVOs) to perform credentialing on behalf of healthcare organizations.

Verisys, with its continuous monitoring of federal and state provider exclusion databases and state licensing boards and access to primary source data, eases the administrative burden for healthcare organizations while ensuring organizations continue to meet legal and regulatory requirements. Verisys can streamline the credentialing process, freeing you to focus more resources on patient care while protecting you from liability and ensuring your patients receive the highest quality of care.

Juliette Willard Written by Juliette Willard
Healthcare Communications Specialist
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