The Joint Commission Relaxes Process for Credentialing Independent Pathologists

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Effective January 3, 2018, The Joint Commission (TJC) has revised its standards to no longer require TJC-accredited hospitals, critical access hospitals, and ambulatory care organizations to credential and privilege pathologists that provide diagnostic services through reference laboratories. TJC Introduction to Leadership Standard LD.04.03.09 generally requires that each hospital, critical access hospital or ambulatory care organization credential and privilege all licensed independent practitioners from whom it receives laboratory services under a contractual relationship. A new exception has been added to the general rule to state that the hospital, critical access hospital or ambulatory care organization no longer needs to credential or privilege practitioners where laboratory services are provided by a pathologist through a contracted reference laboratory that is compliant with the Clinical Laboratory Improvement Amendments (CLIA) regulations. The CLIA regulations set forth rigorous standards for the provision of pathology services and for the qualifications of personnel performing such services. As a result, as long as the reference laboratory is in compliance with the CLIA regulations, TJC views additional credentialing and privileging by hospitals, critical access hospitals and ambulatory care organizations as unnecessarily duplicative. It should be noted that credentialing and privileging is required under TJC standards where a pathologist provides his or her own professional service, such as consulting in the laboratory where a specimen was collected or prepared.

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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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