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Credentialing & privileging details


Before a practitioner may provide services in a hospital, he or she must have their qualifications evaluated and verified. This process, known as  credentialing, ensures an individual possesses the necessary qualifications to provide medical services to patients. Once a practitioner is credentialed, the hospital engages in the privileging  process, which will assess the practitioner’s competence in a specific area of care. 

Telehealth providers, despite not being physically located at the hospital they are providing services to, must also go through the credentialing and privileging process for that distantly located institution. To credential and privilege a physician can be a lengthy and expensive process, utilizing a good amount of resources. However, hospitals that have limited access to specialists need to contract with practitioners in other locations to provide virtual care to their patients.   

The alternative is that their patients have to travel to receive that care or go without it. Telehealth has helped these institutions provide such services while allowing a patient to remain in his or her community. In the past, hospitals relied on “privileging by proxy” standards that  The Joint Commission (TJC), a hospital accrediting organization, has utilized to make the credentialing and privileging process less burdensome on facilities utilizing telehealth. The process allowed the hospital to receive services to accept the distant site (where the telehealth provider is located) hospital’s credentialing and privileging decisions.  It cut down on time, duplication of work, and expense. 

The Centers for Medicare & Medicaid Services (CMS) identified TJC’s privileging by proxy standards as conflicting with their medicare Conditions of Participation (COPs). To participate in and receive reimbursement from the Medicare or Medicaid programs, a hospital must be certified as complying with the medicare COPs.  Therefore, TJC’s process was rendered invalid. This created a difficult situation for many hospitals, particularly small and rural entities who could not afford to hire exclusively on-site specialists to serve their communities’ needs. 

To resolve this conflict while still maintaining safeguards on quality and safety, CMS approved regulations in July 2011 that would allow hospitals (and other health care organizations) to use a similar credentialing-by-proxy process that the TJC had once utilized. TJC followed suit with similar standards that were approved in December, 2011. 

The approved process is optional for hospitals to use.  Should an institution choose, it may still go through the complete credentialing and privileging process of verifying a practitioner’s qualifications.  However, if a hospital wished to utilize the credentialing by a proxy process, certain requirements must be met: 

  • There must be a written agreement between the two parties.
  • The distant-site hospital is a medicare-participating hospital or telemedicine entity.
  • The telehealth provider is privileged at the distant-site hospital.
  • A current list of the telehealth provider’s privileges is given to the originating-site hospital.
  • The telehealth provider holds a license issued or is recognized by the state in which the originating-site hospital is located.
  • The originating-site hospital has an internal review of the telehealth provider’s performance and provides this information to the distant-site hospital.
  • The originating-site hospital must inform the distant-site hospital of all adverse events and complaints regarding the services provided by the telehealth provider.