Contracted Services: Ensuring Compliance with the CMS Hospital CoP, Joint Commission and DNV Standards

Event Information
Product Format
Prerecorded Event
Sue Dill Calloway, RN, MSN, JD
Conference Date
Thu, Oct 20, 2016
90 minutes
Product Description

Hospital Contract Services Compliance with CMS CoP Standards, Joint Commission and DNV

Contracts have become a recent hot topic with increased scrutiny by both the Joint Commission and CMS. Joint Commission has both a contract services tracer and a standard on contract management. Recently, a memo had been issued by CMS summarizing the deficiencies received by hospitals, and many of them were related to contract management.

These days, hospitals are frequently asked why they have contracted with certain entities. It is important for hospitals to evaluate the contracted services to ensure compliance with the provisions included in contract regulations as well as standards with Board oversight. The bottom line is – irrespective of the fact that the hospital in question, contracts out or uses its employees for its work, it needs to still evaluate the services and ensure that patients get good quality care.

Join this session by expert speaker Sue Dill Calloway, RN, MSN, JD, CPHRM, CCMSCP, to understand the hospitals standards accredited by DNV-GL, closely cross-walked to the CMS CoPs. The session is going to cover all of the contract requirements for hospitals accredited by the Joint Commission—a standard that has amended every year for the past three years. Sue will also cover the standards for hospitals accredited by DNV-GL.

In addition, this webinar will discuss the CMS hospital condition of participation requirements for contracts. Every hospital that accepts Medicare or Medicaid reimbursement must follow the CMS contract regulations and interpretive guidelines. A contract is mandatory for the board to have, including telemedicine facilities that are used for telecommunication and teleradiology. This session will discuss the components of this contract.

Session Highlights:

  • The Joint Commission’s contract standard in the leadership chapter
  • Understand the CMS section in the hospital conditions of participation which includes all requirements of contracted services
  • Get to know that the same level of care needs to be there irrespective of hospital providing the services directly or through contracted services
  • Understand that CMS requires the Board to make sure that contract services are reviewed as part of the QAPI process
  • Know how hospitals accredited by DNV must also follow their contract management standards

Session Agenda:

The Joint Commission standards LD.04.03.09

  • Contract standard and the EPs
  • Same level of care
  • Updates
  • Hospital leader responsibility for contracted services
  • Safety and quality requirements
  • Limited applicability to patient care services
  • Consults and referrals not subject to requirements
  • Staff competence
  • Credentialing/privileging and CMS interpretive guidelines
  • Transmittal issued
  • CMS changes on telemedicine
  • Performance improvement requirements
  • Ideas on how to review contracts
  • Credentialing and privileging
  • Nature and scope of services
  • Leadership approval of contracts
  • Monitoring the performance of contracts
  • Contracts with other accredited organizations
  • Communicating expectations in writing
  • Contracts that do not meet expectations
  • Continuity of patient care maintained if contract terminated
  • Contract lab services
  • 3 FAQs
  • Telemedicine contracts
  • TJC contract services tracer

CMS Contract Regulations and Interpretive Requirements

  • Introduction into CoPs
  • CMS deficiency memos and areas in contract management cited
  • How to locate current copy
  • Contract part of CMS hospital worksheet
  • List of contracted services required
  • CMS contract section in worksheets
  • Board responsible for contracted services
  • Board action to identify quality problems
  • Performance improvement requirements
  • 2015 Final CMS Work sheet and Contracts

DNV-GL Standards on Contract Management

  • Measurement, monitoring and analysis
  • Board legal responsibilities for contracts
  • Contracted services requirements
  • Ensuring contracts are safe and effective
  • Telemedicine contracts
  • List of contracts required

Summary of contract requirements and recommendations

Who should attend?

  • Director of Accreditation and Regulation
  • Hospital Attorneys
  • Risk Managers
  • Chief Nursing Officer
  • Individuals responsible for contracted services
  • C people (CEO, CFO, CNO, CMO)
  • Quality improvement director
  • Department directors
  • Board members
  • Credentialing committee members
  • Medical staff services professionals
  • Patient safety officer
  • Compliance officer
  • Nurse directors
  • Joint Commission coordinator
  • Regulatory department directors
  • Nurse educators
  • In house legal counsel
  • Contract managers
  • Patient safety officer
  • Anyone responsible for monitoring or assessing contracted services such as department managers and directors

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

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About Our Speaker

Sue Dill Calloway - Hospital Coding Expert

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the...   More Info
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