CMS Says Medical Staff Members on Board of Directors Is Not Necessary

The Centers for Medicare & Medicaid Services (CMS) recently issued final revisions to the Medicare conditions of participation (CoPs) that pertain to medical staff organization and participation in hospital governance. The key revisions include the following:


  • Removing the requirement that a medical staff member serve on the governing body
  • Allowing for a unified and integrated medical staff shared by multiple hospitals within a system


Medical Staff Representation Not Required on Governing Body


CMS has noted that the requirement to include a member of the medical staff on a hospital’s governing body may create conflicts for some hospitals, particularly public and nonprofit hospitals, where state and local laws may require members of the governing body to be either publicly elected or appointed by the governor or other official(s). As an alternative, CMS has added a provision requiring a hospital’s governing body to directly consult with the individual responsible for the organized medical staff of the hospital, or his or her designee.


CMS defined “direct consultation” as a meeting initiated by “the governing body or a subcommittee of the governing body, with a medical staff leader or leaders, either face-to-face or via a telecommunications system permitting immediate, synchronous communication.”


Direct consultation must include discussion of matters related to the quality of medical care provided to patients and must occur at least twice during either a fiscal or calendar year.” (CMS Revises Medicare CoPs on
Medical Staff Governance and Participation, AHLA, May 19, 2014)


Additional details provided by CMS include:

  • It is up to the governing body to determine the number of consultations needed based on the particular circumstances of the hospital.
  • There must be documented evidence that the governing body is appropriately responsive to any periodic and/or urgent requests from the individual responsible for the organized medical staff for timely consultation on issues related to the quality of care.


Unified and Integrated Medical Staff


Until recently, CMS prohibited a unified and integrated medical staff for a multi-hospital system. That prohibition has been modified to enable the medical staff of each hospital to voluntarily integrate itself into a larger system medical staff. Although the specifics have been left to the medical staffs and governing bodies, CMS requires that:


  • The medical staff at each separately certified hospital in the system must determine, by majority vote, whether to participate in or opt out of a unified and integrated medical staff structure
  • The unified medical staff must have bylaws, rules and requirements describing its processes for self-governance, appointment, credentialing, privileging and oversight; its peer review policies, and due process guarantees; and must have a process to advise medical staff members of the right to opt out
  • The unified medical staff must be established in a manner that takes into account each hospital’s unique circumstances and any significant differences in patient populations and services offered
  • The unified medical staff must give due consideration to the needs and concerns of members of the medical staff, regardless of practice or location, and the hospital must have mechanisms to ensure that issues localized to particular hospitals are duly considered and addressed.


NOTE: Hospitals and systems considering medical staff integration “should keep in mind CMS’ admonition that permitting the use of a system governing body or medical staff does not mean that compliance with other hospital COPs may be demonstrated at the system level. Each separately participating hospital is still required to demonstrate compliance with all other COPs to participate in Medicare.” (CMS Revises Medicare CoPs on
Medical Staff Governance and Participation, AHLA, May 19, 2014)


Additional CMS Provisions in the Revised Final Rule


CMS has long required that the medical staff be composed of doctors of medicine and osteopathy. With its revised final rule, it now has noted that the medical staff may also include other categories of physicians and non-physician practitioners eligible for appointment by the governing body under state laws. State laws will still control, but CMS noted there is nothing in the CoPs that prevents hospitals and medical staffs from establishing certain practice privileges for categories of practitioners excluded from medical staff membership under state law.




iProtean subscribers, Part Two of the advanced Finance course, Strategic Responses to the Competitive Environment, will be published in your library by the end of June. If you enjoyed Part One, you should look forward to a continuation of the details offered by Michael Irwin and Dan Grauman. Topics include the competitive impact of consolidation/M & A activity, the next phase of mergers and acquisitions, the impact on bond ratings and taxable vs. tax-exempt bonds.


For a complete list of iProtean courses, click here.


For more information about iProtean, click here.