QUESTION # 5
Does the CMS define who the responsibility falls on for the review of privilege forms every two years ? Is it the responsibility of the CVO , MSO , Medical Director , Department Chair , or someone else ?
There are no regulatory requirements that specifically state the titles of clinical leaders who must participate in the process of reviewing privilege forms . The healthcare organization should have a policy regarding the review of privilege forms , so you should refer to your policy to determine if any specific clinical leaders have been identified as required members for participating in this process .
Once privilege forms have been developed , the healthcare organization should have a plan for regular review and updating of all privilege forms in order to keep privilege forms relevant and in alignment with current requirements . Some privilege forms will require annual review while others may be reviewed every two years .
Also , in between formal review periods , the healthcare organization should have policies and procedures in place for when new technology , equipment , or procedures are introduced , which would require new privileges to be added to their delineations . They must determine that the privilege / procedure in question should be added to the scope of services for the healthcare organization , and they must develop criteria for what providers will be eligible to apply for the new privilege or procedure .
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