Introduction to Privileges: Credentialing versus Privileging and CMS Requirements

For Medical Services Professionals (MSPs) who are new to the profession, or even seasoned MSPs who are not regularly involved in privileging processes and are interested in a brief refresher, the following are some privilege basics.

Credentialing vs Privileging:

Credentialing is "the process of assessing and confirming the license or certification, education, training, and other qualifications or a licensed or certified healthcare practitioner."

Privileging is "the process of authorizing a health care practitioner’s specific scope and content of patient care services."

Centers for Medicare & Medicaid Services (CMS) Requirements for Privileging:

"The Centers for Medicare & Medicaid Services (CMS), is part of the Department of Health and Human Services (HHS)." The "CMS develops Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. These health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries." The CMS CoPs related to Privileging are:

§ 482.12 Condition of participation: Governing body

(a) Standard: Medical staff. The governing body must:

(6) Ensure the criteria for selection are individual character, competence, training, experience, and judgment; and

(7) Ensure that under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent solely upon certification, fellowship, or membership in a specialty body or society.

§ 482.22 Condition of participation: Medical staff

(c) Standard: Medical staff bylaws. The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must:

(6) Include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges.

Additionally, the CMS requirements for hospital medical staff privileging are outlined in the CMS letter dated November 12, 2004 which requires the hospital’s Governing Body to ensure "that all practitioners who provide a medical level of care and/or conduct surgical procedures in the hospital are individually evaluated by its Medical Staff and that those practitioners possess current qualifications and demonstrated competencies for the privileges granted." The letter further states:

• Specific privileges for each category must clearly and completely list the specific privileges or limitations for that category of practitioner.
• The specific privileges must reflect activities that the majority of practitioners in that category can do and that the hospital can support.
• It cannot be assumed a practitioner can perform every task/activity/privilege listed/specified for the applicable category of practitioner.
• The individual practitioner’s ability to perform each privilege must be assessed and not assumed.
• If the practitioner is not competent to perform one or more tasks/activities/privileges, the list of privileges is modified for that practitioner.
• The Medical Staff must actually examine each individual practitioner’s qualifications and demonstrated competencies to perform each task/activity/privilege he/she has requested from the applicable scope of privileges for their category of practitioner.
• Components of practitioner qualifications and demonstrated competencies would include at least: current work practice, special training, quality of specific work, patient outcomes, education, maintenance of continuing education, adherence to medical staff rules, certifications, appropriate licensure, and currency of compliance with licensure requirements.

Accrediting Bodies and Health Care Organizations to which Privileging is Applicable:

The "CMS also ensures that the standards of accrediting organizations recognized by CMS (through a process called "deeming") meet or exceed the Medicare standards set forth in the CoPs/CfCs." Health Care Organizations seeking CMS approval may choose to be surveyed either by an accrediting body, such as The Joint Commission (TJC), Healthcare Facilities Accreditation Program (HFAP) and DNV-GL; or by state surveyors on behalf of CMS. Types of Health Care Organizations to which the CMS standards apply and also at which Privileging is typically applicable are Hospitals (including acute care, critical access and psychiatric), Surgery Centers, Mental or Behavioral Health Centers, and Federally Qualified Health Centers (FQHCs). This is not to say however, that there are not other Health Care Organization types that perform privileging, these are just the most common, and also the ones that typically have other Accreditation Standards (TJC, HFAP, DNV-GL, AAAHC, HRSA) related to Privileging that they must meet as well, in addition the CMS’s CoPs related to Privileging.