Navigating the complex relationships between providers and their medical staffs is challenging, with any missteps exposing health care organizations to noncompliance that could result in substantial legal liability.

Epstein Becker Green provides full-service support to medical staff leaders and administration for hospitals and health systems of all sizes across the country to help them reduce that risk.

Our team’s counsel is based on years of experience within hospitals and health systems. Our combined experience also gives us the ability to quickly adapt to evolving issues in the practice of health care law and, specifically, with respect to medical staff matters. By understanding what works well—and what doesn’t work—in the provider setting, we give practical advice and solutions to solving both day-to-day and complex medical staff issues.

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Our Services

Working closely with medical staffs and health care organizations nationwide, Epstein Becker Green provides practical counsel/advice on credentialing, medical staff appointment/privileging, and peer review issues; collaborates with medical staff leadership to create, customize, operationalize, and implement medical staff documents, processes, and procedures; and supplies strategic and operational support.

Specifically, we offer services with respect to the following areas:

Medical Staff Governing Documents

  • Customize, coordinate, and manage all aspects of system-wide projects to standardize the medical staff governing documents at each hospital within the health system.
  • Review, critique, and interpret medical staff governing documents.
  • Customize, draft, and amend medical staff governing documents, including Medical Staff Bylaws, Credentials Policy, Organization Policy, Fair Hearing Policy, Conduct Policy, Wellness Policy, Peer Review Program/Professional Practice Evaluation (FPPE/OPPE) Policy, Advanced Practice Clinician Policy, and Rules & Regulations.
  • Implement and operationalize medical staff governing documents in coordination with Credentialing Verification Organization (CVO) staff, Medical Staff Office staff, Medical Staff officers, department chairs, and committee chairs.

Medical Staff Structure

Provide advice relating to:

  • Medical staffs within health systems, including system group medical practice matters.
  • Unified medical staffs.
  • Medical staff restructuring related to hospital mergers, including medical staff-related due diligence review.
  • Critical access hospital medical staffs.
  • Acute care hospital medical staffs, including provider-based locations.
  • Ambulatory surgery center (ASC) medical staffs.

Medical Staff Credentialing

Provide advice and guidance to clients on the following:

  • Applications for Medical Staff appointment and clinical privileges.
  • Applications for clinical privileges for Advanced Practice Clinicians (APCs).
  • Telemedicine credentialing by proxy.
  • Credentialing verification process.
  • CVOs.
  • National Committee for Quality Assurance (NCQA) standards and the National Practitioner Data Bank (NPDB) guidebook.

Medical Staff Appointment and Clinical Privileging

Provide advice relating to:

  • Practitioner applicants for Medical Staff appointment and/or clinical privileges.
  • APC applicants for clinical privileges.
  • Medical Staff appointment/reappointment process.
  • Clinical privileging process.
  • Delineation of clinical privileges (e.g., clinical privilege sets).
  • Practitioner/APC credentials file.
  • Scope of practice and licensure.
  • Practitioner/APC conduct issues and impairment issues.
  • Formal corrective action procedure.
  • Summary suspension.
  • Automatic suspension and automatic termination of Medical Staff appointment and/or clinical privileges.
  • Fair hearing and appeal process and the Health Care Quality Improvement Act (HCQIA).
  • Reporting to state licensure boards and the NPDB.
  • Interstate telehealth issues, including prescribing, scope of practice, professional licensing, and APC supervision.

Peer Review and Professional Practice Evaluation

Provide advice and guidance to clients on the following:

  • Practitioner and APC peer review process from a health system perspective, for hospital medical staffs, in the ambulatory setting, and for health system group medical practices.
  • Case review procedure using a multidisciplinary peer review committee, specialty peer review committees, system joint specialty peer review committees, etc.
  • Customized template peer review committee letters.
  • Development of quality assurance and quality review processes
  • External (third party) peer review.
  • FPPE process for practitioners/APCs granted new privileges.
  • FPPE process for practitioners/APCs with quality of care concerns.
  • OPPE process.
  • Patient safety organizations (PSOs), including preparation of appropriate PSO policies and operational matters concerning participation in a PSO.
  • Practitioner/APC quality file.
  • Sharing of peer review information and the peer review privilege.

Accreditation and Medicare Regulations

Advise clients on the following:

  • The Joint Commission (TJC), Det Norske Veritas (DNV), and Accreditation Commission for Healthcare (ACHC)/Healthcare Facilities Accreditation Program (HFAP) accreditation standards.
  • Medicare hospital, critical access hospital, and ASC conditions for coverage.
  • EMTALA regulations, including physician call coverage, use of APCs, etc.

Hearing Officer Services

  • Serve as a neutral third-party hearing officer to preside over the Medical Staff hearing and appeal process consistent with the applicable medical staff governing documents and the HCQIA immunity provisions.

Education and Training

  • Regularly facilitate education and training for hospital and medical staff leadership, as well as state and national trade associations, on trending issues and best practices for medical staff management.

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