Credentialing & Privileging

A Guide to Emergency Credentialing and Privileging for Healthcare Staff During COVID-19 Pandemic

By NAMSS Staff

This blog was first posted on NAMSS Insights: A Blog for Medical Services Professionals.

The COVID-19 pandemic implements non-pharmaceutical interventions daily, and hospitals and medical professionals are preparing for a large wave of coronavirus cases. Medical professionals and hospitals are eliminating obstacles to provide medical care for COVID-19 patients as quickly as possible, such as waiving the need to credential and privilege additional medical professionals in events of emergency or disaster. Here are some key takeaways and resources from recent events:

On March 13, 2020, the president declared a State of National Emergency.  

Key takeaways:

1. Grants the Secretary of Health and Human Services (HHS) Emergency Authority to temporarily waive Medicare and Medicaid program requirements and HIPAA.
2. The Secretary of HHS is granted power to waive “Conditions of Participation or other certification requirements” and to waive requirements that medical professionals be licensed in the state they practice in.
3. The declaration exempts healthcare practitioners who do not have one or more requirements from sanctions or penalties.

Read more here for additional COVID-19 updates from HHS.

California Governor Newsom declared a State of Emergency for California.

Key takeaways:  

1. Permits any out-of-state medical professionals to provide services with respect to licensing and certification as described in the Multi-state Emergency Management Assistance Compact.
2. The Medical Board of California is granted permission to re-activate expired licenses of physicians if the license expired within the past five years using an accelerated approval process.

The Joint Commission Emergency Management Standards outline hospital requirements in the event of emergency or disaster.

Key takeaways:

1. Under the standards, a hospital in the event of disaster “may use a modified credentialing and privileging process on a case-by-case basis for eligible volunteer practitioners” if the hospital implements its Emergency Operations Plan and there is a need for additional medical assistance.
2. These disaster privileges may be granted only if the volunteer practitioner presents proof of current licensure, privileging at another medical facility, participation in a state of federal response organization, or governmental approval.
3. A primary source of the hospital may verify the abilities of a volunteer practitioner to act as a licensed independent practitioner during a disaster within 72 hours, and the hospital must have an oversight mechanism in writing.

Read more here.

NAMSS is monitoring the evolving COVID-19 pandemic and is committed to serving you and the medical services profession. View useful resources and information here.