Synergy - September/October 2013 - 17

industry feature

Now	that	you	are	aware	of	the	direct	impact	
of	a	P-B	facility	designation,	how	do	you	
determine	how	many	P-B	facilities	exist,	
what	requirements	must	be	met	and	what	
strategies	should	be	employed?	Take	it	one	
step	at	a	time:
Step One:	Determine	what	P-B	facility	
designations,	if	any,	exist.	The	person	who	
can	give	you	the	most	direct	answer	to	this	
question	is	the	chief	financial	officer.	Now	you	
have	a	list	of	P-B	facilities	on	which	to	focus.
Step Two:	Download	(or	ask	counsel	
to	download)	the	CMS	Provider-Based	
requirements	for	C.F.R.	§	413.65	and	
see	the	Clinical	Services	Integration	
portion	that	contains	critically	important	
requirements.	Review	the	five	areas	of	
the	P-B	requirements	that	relate	to	patient	
care:	clinical	privileges;	clinical	monitoring	
and	oversight;	medical	director	reporting	
relationship;	supervision	and	accountability;	
and	medical	staff	committees.	Create	a	
worksheet	of	requirements	and	work	your	
way	through	them	and	assure	compliance	
with	respect	to	each	P-B	facility.
The	remaining	four	steps	need	to	be	
individually	applied	to	each	P-B	facility:
Step Three:	Determine	what	services	are	
being	provided	at	the	P-B	facility	that	require	
clinical	privileges.	Now	follow	the	process	in	
your	medical	staff	governing	documents	to	
create	clinical	privilege	sets	specific	to	care	
delivered	at	the	P-B	location.	This	may	be	
a	challenge	as	P-B	facilities	often	provide	
different	services	from	those	traditionally	
provided	at	a	Main	Provider,	such	as	primary	
care,	mental	health,	urgent	care,	etc.
Step Four: Determine	which	practitioners	
and	mid-level	providers	are	providing	
services	at	the	P-B	facility.	Also	determine	
whether	any	of	these	individuals	currently	
have	an	appointment	and/or	clinical	
privileges	at	the	Main	Provider.	Those	who	
are	currently	privileged	merely	need	to	go	

through	the	process	of	granting	applicable	
additional	clinical	privileges.	Those	not	
currently	privileged	will	go	through	the	
complete	initial	credentialing/privileging	
process.	This	may	also	impact	upon	
your	current	medical	staff	categories.	For	
example,	if	a	physician	practices	only	at	the	
P-B	facility,	will	he	or	she	be	appointed	to	
the	active	medical	staff	with	the	ability	to	
hold	office?
Step Five:	A	P-B	facility	is	viewed	by	CMS	as	
any	other	hospital	department	at	the	Main	
Provider.	This	means	that	comparable	clinical	
monitoring	and	oversight	requirements	
exist.	And	requires	creation	of	professional	
practice	evaluation	parameters	(focused	and	
ongoing)	that	reflect	the	clinical	privileges	
granted.	Again,	these	processes	may	be	
very	different	from	what	are	traditionally	
reviewed.	For	example,	the	facility	may	be	
purely	office-based	i.e.,	it	may	only	provide	
primary	care	services.	Alternatively,	it	may	
be	an	urgent	care	center	and,	because	it	is	
Provider-Based,	it	now	has	certain	EMTALA1	
requirements	that	did	not	exist	before.
Step Six: Incorporating	P-B	specialties	into	
the	Main	Provider’s	peer	review	process	
may	be	a	challenge.	The	medical	staff	
traditionally	provided	oversight	of	inpatient	
care.	This	oversight	then	expanded	to	
outpatient	care	(that	was	provided	within	
the	main	hospital).	Requesting	medical	
staff	leaders	to	extend	their	oversight	to	
locations	away	from	the	Main	Provider	and	
to	services	not	traditionally	provided	at	the	
Main	Provider	may	not	only	be	difficult,	
but	also,	may	be	outside	of	their	areas	of	
expertise.	It	is	important	to	educate	medical	
staff	leaders	as	well	as	to	create	new	
medical	staff	committee(s).	The	majority	of	
the	members	of	this	new	committee	should	
be	drawn	from	the	P-B	facility	as	they	are	
the	most	knowledgeable	in	this	area.	If	you	
have	more	than	one	P-B	facility	providing	
comparable	services,	consider	creating	a	

The reality is that the fiscal decision to be a
Main Provider and to designate a facility as
a P-B location under your CMS number has
direct implications for medical staff leaders.

Take it one step at
a time:
Step One:	Determine	what	P-B	facility	
designations	exist	
Step Two: Download	the	CMS	
Provider-Based	requirements	for	C.F.R.
Step Three:	Determine	what	services	
are	being	provided	at	the	P-B	facility	
that	require	clinical	privileges.
Step Four: Determine	which	
practitioners	and	mid-level	providers	
are	providing	services	at	the	P-B	
facility.
Step Five:	A	P-B	facility	is	viewed	
by	CMS	as	any	other	hospital	
department	at	the	Main	Provider.
Step Six: Incorporating	P-B	specialties	
into	the	Main	Provider’s	peer	review	
process	may	be	a	challenge.

joint	committee	from	these	facilities.	This	
committee	needs	to	report	back	into	the	
traditional	medical	staff	structure	(peer	
review,	medical	executive	committee,	etc.).
These	six	steps	will	start	the	process	toward	
compliance	with	P-B	requirements.	The	
obstacles	to	compliance	include:	ignorance	
of	having	P-B	facilities,	failure	to	research	
and	determine	the	extent	of	responsibilities	
and	non-effort	to	comply	with	requirements.	
Draw	upon	the	expertise	of	legal	counsel	
in	educating	medical	staff	leaders	in	
requirements	and	responsibilities,	and	in	
assessing	what	changes	may	be	needed	
to	medical	staff	governing	documents	and	
related	policies.	■

Catherine Ballard’s practice is “quality of care”
focused including governance issues, medical staff
matters, accreditation issues, and peer review and
hearing/presiding officer support.
Melinda Whitney, director of QMCG’s quality
management services supports medical executive
committees with clinical quality assessment,
medical staff peer review, committee activity and
MSO administration.
1
The	Emergency	Medical	Treatment	&	Active	Labor	Act,	42	U.S.C.	§	
1395dd.

September/Oct Ober 2013 SYNERGY

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Synergy - September/October 2013

Table of Contents for the Digital Edition of Synergy - September/October 2013
