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

Contract Management - Demystifying the CMS Hospital CoPs and the TJC Standards

Contracts have become a recent hot topic with increased scrutiny by both the Joint Commission and CMS. CMS recently issued a memo summarizing deficiencies received by hospitals and many were related to contract management. Hospitals must also have a process to evaluate the contracted services with certain entities. The board is responsible for oversight of contracted services and tips to ensure compliance will be discussed.

This presentation will cover all of the contract requirements for hospitals accredited by the Joint Commission and changes. This standard was amended every year for the past three years. The CMS telemedicine standard also updated a section in the Joint Commission contract standards. It is covered in the TJC contract tracer.

The webinar by hospital & compliance expert , Sue Dill Calloway, will include the CMS hospital CoPs requirements for contracts. Every hospital that accepts Medicare or Medicaid reimbursement must follow the CMS contract regulations and interpretive guidelines. The board will have to have a contract with the telemedicine facility that they are using for teleradiology and telecommunication and this program will talk about what must be in the contract. CMS has added a section to the final CMS worksheets to ensure the surveyors address the contract management issue. Summary of contract requirements and recommendations will be discussed.

Session Objectives

  • Recall that the Joint Commission has a contract standard in the leadership chapter

  • Describe that the same level of care is required whether the hospital provides the services directly or through contracted services

  • Recall that CMS requires that Board to make sure that contract services are reviewed as part of the QAPI process

  • Discuss the standards for hospitals accredited by DNV-GL which are closely cross- walked to the CMS CoPs.

Session Agenda

  • The Joint Commission standards LD.04.03.09

    • Contract standard and the EPs, Updates

    • Hospital leader responsibility for contracted services

    • Limited applicability to patient care services

    • Consults and referrals not subject to requirements

    • Credentialing/privileging and CMS interpretive guidelines

    • Performance improvement requirements

    • Ideas on how to review contracts, Monitoring the performance of contracts

    • Credentialing and privileging, Nature and scope of services

    • Contracts with other accredited organizations

    • Communicating expectations in writing

    • Contracts that do not meet expectations, Leadership approval of contracts

    • Continuity of patient care maintained if contract terminated

    • Contract lab services, 3 FAQs

    • Telemedicine contracts, CMS changes on telemedicine

    • 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

    • CMS contract section in worksheets

    • Board responsible for contracted services

    • Board action to identify quality problems

    • Final CMS Work sheet and Contract requirement

  • 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

    Who Should Attend

    • Director of Accreditation and Regulation

    • Hospital Attorneys, Risk Managers, In house legal counsel

    • Individuals responsible for contracted services

    • C people (CEO, CFO, CNO, CMO)

    • Quality improvement director

    • Board members, Department directors

    • Credentialing committee members

    • Medical staff services professionals

    • Patient safety officer, Compliance officer

    • Nurse directors, Nurse educators

    • Joint Commission coordinator

    • Regulatory department directors

    • Contracted services department managers and directors

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

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Webinar Information

Date / Time : 22 Oct 2019 @ 01:00 PM EST

Duration : 120 Minutes

Number Of Attendees

Avail Discount At Checkout

For Group Registration
Contact 1888-437-7218 or
Email us at

Speaker Detail

Sue Dill Calloway RN, Esq. CPRHM CCMSCP AD, BSN, MSN, JD

Alt Text Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is also the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation and a board member. She was a director for risk management and patient safety for readmore...


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Webinar Information

Date / Time : 22 Oct 2019 @ 01:00 PM EST

Duration : 120 Minutes

Number Of Attendees

Avail Discount At Checkout

For Group Registration
Contact 1888-437-7218 or
Email us at