Credentialing Telehealth Providers: When and How to Use Delegated Credentialing

Davis Brown Law Firm

Davis Brown Law Firm

With the growth in telemedicine, Critical Access Hospitals have a renewed interest in exploring delegated credentialing. Several years ago, the Centers for Medicare and Medicaid Services (CMS) modified the conditions of Critical Access Hospital participation to streamline medical staff credentialing for telehealth providers.

Rather than independently credentialing each telehealth provider, the revised Conditions of Participation allow a Critical Access Hospital to rely on the credentialing and privileging decisions of a distant site hospital or telemedicine entity providing the telehealth services. 

This can be a significant cost saving for hospitals and reduces the administrative burden associated with credentialing and re-credentialing each provider.

Medical Staff Processes

To use delegated credentialing the telemedicine entity the hospital contracts with must have a medical staff process in place that meets Medicare guidelines to credential and privilege the providers. 

This can easily be satisfied when the telemedicine provider is a Medicare-participating hospital with an organized medical staff. However, it is less likely to be met when telemedicine services are provided by an independent practice. In such cases, delegated credentialing may not be possible unless the telemedicine provider organizes a formal medical staff that can meet Medicare’s requirements.


Critical Access Hospitals contracting with a distant site hospital or telemedicine entity with an organized medical staff process to make credentialing and privileging decisions can rely on their credentialing and privileging decisions if it satisfies the following requirements:

  • Has a written agreement in place with the distant site outlining the roles and responsibilities of each party and addressing specific items required by the Medicare Conditions of Participation
  • Its governing board has approved the written agreement and the decision of the hospital to rely on the distant site’s credentialing and privileging decisions
  • It has a process in place to forward quality concerns, adverse events, complaints, or other issues regarding a telemedicine provider to the distant site

Bylaw Changes

We also recommend the hospital update its medical staff bylaws to provide for delegated credentialing and to create a separate medical staff category for telehealth providers. Notably, delegated credentialing can only be used for providers who deliver patient care services through telemedicine only. Any provider who delivers services requiring privileges at the hospital would need to be independently credentialed by the hospital.

Hospital Checks on Providers

Once the Critical Access Hospital has implemented delegated credentialing for telemedicine providers, it does not have to separately approve each telemedicine provider. The distant site will provide the hospital with a list of the telemedicine providers and the privileges they are granted. The distant site must update the list as the providers and/or their privileges change. For compliance purposes, we recommend the hospital confirms each provider’s license and include the providers in their excluded provider/debarment checks. The hospital will also need to establish a process to notify the distant site of any adverse issues relating to a telemedicine provider.

The Big Picture

It has limitations, but delegated credentialing can be extremely beneficial to Critical Access Hospitals for those telehealth-only services. When using delegated credentialing, Critical Access Hospitals can refer to this checklist:

  • Medical staff process - the entity providing telehealth services for the hospitals must have a medical staff process to make credentialing and privileging decisions. This process can only be used for those providers who do not provide patient care services on-site at the hospital
  • Medicare requirements - the Critical Access Hospital must also ensure it has a written agreement in place with the distant site that meets Medicare’s requirements
  • Provider checks - Critical Access Hospitals should confirm each provider’s license and include them in the excluded provider/debarment checks

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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