Medical Staff and Telemedicine: Meeting CMS CoPs (W6006)-Medical Staff and Telemedicine: Meeting CMS CoPs 2026 Presentation

Medical Staff and Telemedicine: Meeting CMS CoPs 2026 Presentation

Pdf Summary

The document summarizes CMS Conditions of Participation (CoPs) related to medical staff governance, credentialing/privileging, and telemedicine for acute care hospitals and Critical Access Hospitals (CAHs). CMS surveys and enforcement can lead to citations or loss of Medicare participation when hospitals fail to follow CoPs, bylaws, policies, or scope-of-practice rules.<br /><br />Common citation causes include practitioners working outside their scope or granted privileges not supported by bylaws, inadequate oversight of quality through QAPI, missing/late/incomplete history and physicals (H&Ps), weak competency criteria, failure to credential and re-privilege at least every two years, and failure to document granted privileges.<br /><br />For acute hospitals, the governing body is responsible for ensuring medical staff requirements are met, determining which practitioner categories are eligible for medical staff appointment, and consulting directly with medical staff leadership at least periodically (CMS recommends twice yearly). Medical staff must be organized under governing-body-approved bylaws, remain accountable for quality of care, and—if a medical executive committee exists—be majority MD/DO. Credentialing requires verification of licensure, training, experience, competence, and references; ongoing appraisals are expected at least every 24 months. Bylaws must define categories, qualifications, organizational structure, privileging criteria, due process, and H&P timing requirements, including updates prior to surgery/anesthesia. Recent guidance allows assessments instead of comprehensive H&Ps for certain outpatient anesthesia cases if supported by policy.<br /><br />CAHs must have professional staff including one or more physicians and ensure provider availability, supervision, chart/record review, and physician involvement in oversight; telemedicine may help meet consultation/availability expectations but cannot replace EMTALA requirements for on-site response when needed.<br /><br />Telemedicine CoPs permit “proxy credentialing” by relying on distant-site hospital/entity credentialing and privileging if a written agreement includes required elements (Medicare participation where applicable, licensure in the patient’s state, lists of providers/privileges, and performance feedback including adverse events and complaints). The document also recommends robust telemedicine policies, contract management, and adherence to national standards and state licensure rules.

Keywords

CMS Conditions of Participation (CoPs)

medical staff governance

credentialing and privileging

proxy credentialing telemedicine

acute care hospital compliance

Critical Access Hospital (CAH) requirements

QAPI quality oversight

history and physical (H&P) documentation

scope of practice and bylaws enforcement

Medicare survey citations and enforcement