Home Events CMS Hospital CoPs and TJC Telemedicine Standards, Credentialing and Privileging

CMS Hospital CoPs and TJC Telemedicine Standards, Credentialing and Privileging

NDHA is an approved provider of continuing education by the North Dakota Board of Examiners for Nursing Home Administrators.

Date: 3/22/2022

9:00 – 11:00 AM Central time


Registration fees:       $175 per NDHA member  |  $225 per non-member


Although telemedicine services have been approved for payment by the Centers for Medicare & Medicaid Services (CMS) for many years, the COVID-19 pandemic has resulted in its dramatically expanded use. A government report from the Assistant Secretary for Planning and Evaluation (ASPE) reported that telehealth Medicare fee-for-service visits increased from 840,000 in 2019 to 52.7 million in 2020.

It is anticipated that the telemedicine boom will outlive the pandemic, and CMS has made many changes to telemedicine standards and regulations. Every acute hospital and critical access hospital offering telemedicine should ensure compliance.

This program will discuss the most problematic standards in the telemedicine interpretive guidelines. The most frequently cited deficiency standard is the hospital’s failure to have the required sections in the contract for telemedicine services. This webinar will cover what provisions should be in the telemedicine contract.

This webinar will also review the CMS conditions of participation (CoP) and interpretive guidelines for all hospitals regarding their telemedicine standards. The regulations cover the credentialing and privileging process for physicians and practitioners providing telemedicine services.


Learning Objectives

At the conclusion of this session, participants should be able to:

  • Discuss that there is both a regulation and CMS interpretive guidelines that are now part of the hospital CoPs on telemedicine credentialing.
  • Recall that CMS includes a mechanism for all hospitals to use proxy credentialing with a Medicare-certified hospital or other telemedicine entities.
  • Describe that the hospital must have a written agreement that specifies the responsibilities of the distant-site hospital to meet the required credentialing requirements.
  • Recite that Joint Commission has standards on telemedicine in the leadership chapter.



Laura A. Dixon is the president of Healthcare Risk Education and Consulting. She previously served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020.  In her role, Ms. Dixon provided consultation and training to facilities, practitioners and staff in multiple states.

Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services and pain management.  Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California.  In this capacity, she provided consultation to the physicians and staff for the western United States.

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, a Doctor of Jurisprudence degree from Drake University College of Law, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing.  She is licensed to practice law in Colorado and California.

This speaker has no real or perceived conflicts of interest that relate to this presentation.



Mar 22 2022


9:00 am - 11:00 am

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