October 22, 2020


120 Min


Sue Dill Calloway RN, Esq. & Laura A. Dixon, BS, JD, RN

What Every Hospital Should Know About the Law, TJC standards and the CMS Interpretive Guidelines
Trending 10/22/2020

COVID-19 gives telemedicine a larger role in diagnosis. Communicating remotely protects clinicians and patients from transmission of the SAS-CoV-2 virus. The solution to do this was so obvious that the federal government, some states, and health insurers quickly suspended regulations that limited telemedicine. It is also anticipated that the telemedicine boom will outlive the coronavirus. CMS has made many changes to telemedicine during the COVID-19 pandemic. This will be discussed as well as the 1135 telemedicine waivers.

With all of the recent activity in the area of telemedicine are you sure your hospital is compliant with the regulatory standards? Every hospital and critical access hospital that is doing telemedicine should ensure compliance. Both will be discussed along with the new tag numbers for critical access hospitals in 2020.

Are you familiar with the federal regulation on telemedicine along with the CMS hospital CoP interpretive guidelines? CMS has been issuing quarterly reports of the number of hospital deficiencies and this program will discuss the most problematic standards in the telemedicine interpretive guidelines. The most problematic standard is the failure of the hospital to have the required sections in the contract for telemedicine services. This webinar will cover what provisions need to be in the telemedicine contract.

The Centers for Medicare and Medicaid Services (CMS) have conditions of participation (CoP) interpretive guidelines for all hospitals regarding their telemedicine standards. These were based on the federal regulations. The regulation and interpretive guidelines also impact hospitals accredited by the Joint Commission (TJC). In fact, TJC made changes to the crosswalk with the final CMS standards. These impact both large hospitals, small and rural hospitals and critical access hospitals. 

The regulations cover the credentialing and privileging process for physicians and practitioners providing telemedicine services. This revised process is less burdensome which means it is now a less financial burden for hospitals. CMS allows hospitals to credentialing by proxy. Hospitals are required to have a written agreement that meets certain criteria. Come learn all about the regulations and interpretive guidelines and the responsibilities of the board, medical staff and hospitals to ensure compliance with the regulations or ensure you are in compliance.

These standards have the effect of being able to bring the most up to date care to the most remote places. Many facilities are investing in equipment to support telemedicine. Make sure your facility is in compliance with the regulations and interpretive guidelines.

Webinar Objectives

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

Webinar Agenda

  • Introduction
  • COVID-19 telemedicine and 1135 waivers
  • 16-page federal law
  • 27-page interpretive guidelines by CMS for CoPs
  • CMS deficiencies in telemedicine
  • Includes hospitals and critical access hospitals
  • Definitions of distant site telemedicine entity (DTSE)
  • CoP board changes
  • Written agreement required
  • Requirements in the written agreement
  • Privileges based on medical staff recommendations
  • Credentialing by proxy
  • Agreements with Medicare-certified hospitals
  • Agreements with DTSE
  • Ensuring compliance with the CoPs
  • Effect on Joint Commission hospitals
  • Basic hospital functions
  • Reliance on the C&P decisions of the distant site
  • Peer review issues
  • Adverse events and notification
  • Periodic appraisals
  • Complaints received about the distant site physician
  • Third-party verification organizations
  • Question and answer session
  • Where CoP tag numbers are changed

Who should Attend

  • Chief Medical Officer
  • Medical Staff leader
  • Credentialing and Privileging Professionals
  • Teleradiology Professionals
  • Chief Nursing Officer
  • Chief Operating Officer
  • Director of Radiology
  • Hospital legal counsel
  • Medical Staff Office  personnel
  • Risk manager
  • Compliance officer
  • Patient safety officer
  • Legal counsel
  • Nurse educator
  • CAH telemedicine standard tag numbers are changing
  • Joint Commission director
  • Accreditation Director
  • Director of Regulatory Affairs
  • Telemedicine director
  • Anyone involved or in contracting for telemedicine services 


Webinar Planet Speaker Sue Dill Calloway RN, Esq.

Sue Dill Calloway RN, Esq.

(A.D., B.A., B.S.N., M.S.N., J.D. CPHRM, CCMSCP, CC)

Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is also the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation and a board member. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal, patient safety, and risk management issues and writes numerous publications. Sue has been a medico-legal consultant for over 30 years. She has done many educational programs for nurses, physicians, and other health care providers on topics such as nursing law, ethics and nursing, malpractice prevention, HIPAA medical record confidentiality, emergency department patient safety, and risk, EMTALA anti-dumping law, Joint Commission issues, CMS issues, documentation, implementing a falls program, medication errors, medical errors, documentation, pain management, federal laws for nursing, sentinel events, MRI Safety, Legal Issues in Surgery, patient safety and other similar topics. She is a leading expert in the country on CMS hospital CoPs issues and does over 250 educational programs per year. She was the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program.

Webinar Planet Speaker Laura A. Dixon

Laura A. Dixon


Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management, and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consulting and training to facilities, practitioners and staff in multiple states. Such services included the creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products. 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 patient safety and risk management consultation to the physicians and staff for the western United States. Ms. Dixon’s legal experience includes representation of clients for Social Security Disability Insurance providing legal counsel and representation at disability hearings and appeals, medical malpractice defense, and representation of nurses before the Colorado Board of Nursing. As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.