HRSA Compliance: Temporary Privileges

It used to be very commonplace for health centers to describe in their Credentialing and Privileging Policy how they might grant “temporary privileges”. As the COVID-19 global pandemic began to hobble health center staff, health centers took a hard look at their “temporary privileging” policies in case they needed to bring in additional staff on a short-term basis. Though both the HRSA Compliance Manual and HRSA Site Visit Protocol are silent regarding granting “temporary privileges”, guidance from HRSA (HRSA PAL 2017-07, superseded now by HRSA PAL 2024-01 as of April 1, 2024) does provide some guidance.

The guidance states that:

• Temporary credentialing and privileging may be provided to clinical providers in response to certain “declared emergency situations”.

• A “declared emergency situation” is defined in the PAL as, “an event affecting the overall health center target population and/or the health center’s community at large, which precipitates the declaration of a state of emergency at a local, state, regional, or national level by an authorized public official such as a governor, the Secretary of the Department of Health and Human Services, or the President of the United States”. The PAL gives examples including, “hurricanes, floods, earthquakes, tornadoes, widespread fires, and other natural/environmental disasters; civil disturbances; terrorist attacks; collapses of significant structures within the community (e.g., buildings, bridges); and infectious disease outbreaks or other public health threats”. It goes on to state that in situations where there has not been an official emergency declaration, HRSA will, “…evaluate on a case-by-case basis whether extraordinary circumstances justify a determination that the situation faced by the health center constitutes an “emergency” for purposes of FTCA coverage during a declared emergency”.

• Temporary privileges “may, upon approval by HRSA, use temporary credentialing and privileging processes to fulfill their obligation to ensure that their clinical staff are qualified to provide quality health care services to the health center’s patient population. In such approved situations, the health center’s expedited review and verification process may take into account signed, written findings of the impacted health center’s Chief Medical Officer or applicable clinical department head, as to the following items:

  • Identity: Identity verification must be done by verifying the individual’s federal or state-issued identification documentation (e.g., driver’s license, U.S. passport).

  • Professional Credentials: Licensure verification must be done by primary source verification. “Primary Source Verification” is the process of verifying a credential by directly contacting or obtaining documentation from the original source that issued the specific credential to determine the accuracy of a qualification reported by an individual health care practitioner. For example, primary source verification of medical licensure could be obtained by a health center staff member requesting a copy of the provider’s medical license directly from the Board of Medical Licensing of that state. In the event that primary source cannot be obtained, the health center must document its attempts to obtain primary source verification and may accept a secondary source document (i.e., a copy from the provider). These references should also include information related to any negative professional organization findings, if applicable. Please note that during an emergency, all individuals must adhere to all state licensing laws and requirements when performing services in jurisdictions or states.

  • Claims History: This shall be done by querying the National Practitioner Data Bank. If not possible, they must obtain a secondary source copy of the most recent National Practitioner Data Bank query or a recent health employer (e.g., another deemed health center) may attest in writing that the provider was not the subject of any medical malpractice claims filed or pending within the last 12 months, or, if such claims exist, the applicant should provide explanatory information for each such claim.

  • Fitness/References: This must be assessed by reviewing privileging documentation and/or at least one reference from another recent employer that demonstrates the individual can provide certain identified health services on behalf of the health center. The reference may be provided via email or other electronic correspondence from a recent employer (such as another deemed health center) to the current health center and must clearly state that the recent employer has verified from its existing records that the individual can competently perform the health services identified by the health center. If privileging information cannot be obtained from a recent employer (for example, if the individual is a recent graduate), secondary sources may be used to confirm the provider’s competence to practice, such as a statement or other documentation from a degree-issuing institution.

• Temporary privileges can be granted for no more than 90 days. After 90 days, the impacted health center must have completed all the necessary verification for standard credentialing and privileging and granted full privileges based on that information.

Though the HRSA Compliance Manual does not explicitly promote or condemn the use of temporary provider privileges, we recommend all health centers (regardless of FTCA-deeming status) align their policies with the guidance offered in PAL 2024-01. The FTCA Health Center Policy Manual also may provide guidance on coverage for temporary sites and providers.

If you would like our RegLantern team of HRSA Compliance experts to take a look at your Credentialing and Privileging policy or if you’d like us to perform a remote mock HRSA compliance review, contact us today at support@reglantern.com.

NOTE: Updated April 17, 2024 with release of HRSA PAL 2024-01.