AMA-OMSS delegation update on Medicare Conditions of Participation for hospitals

7 June 2012

On behalf of the American Medical Association (AMA) Organized Medical Staff Section (OMSS), Lawrence Monahan, M.D., FACP provided updates to share with Medical Society of Virginia (MSV) members:

In October 2011, the Centers for Medicare and Medicaid Services (CMS) proposed rules that would have markedly changed the functions, importance and protections of the independent and self-governing medical staff in hospitals. The medical staff has certain requirements involving credentials, privileges, participation, committee service, due process protections for its members, etc. and CMS proposed rules which would have severely revised the Medicare Conditions of Participation (CoPs) for hospitals.

The AMA-OMSS, along with several state and national specialty societies, opposed several important proposed changes and prevented them from becoming a part of the final CMS rule released on May 10, 2012. The final rule on CoPs includes the following improvements:

• The proposed concept of a single medical staff for a multi-hospital system has been removed.
• The proposed concept of the privileging of physicians by the hospital without appointment to the medical staff has been removed.
• The proposed concept of credentialing for medical staff membership in accordance with “hospital policies and procedures” has been removed; the final rule defers to state law and “medical staff bylaws, rules and regulations”.
• The mandatory inclusion of non-physician practitioners on medical staffs (strongly proposed by several other groups) was not adopted.
• A hospital’s governing body must now include at least one medical staff member.

Medical staff bylaws provide a due process for all investigations of medical staff members, as distinctly different from the hospital bylaws, which almost always provide for “at-will employment” of physicians without due process protections of the medical staff bylaws during the investigation of various kinds of possible infractions.

Please visit the AMA-OMSS web-site and read the AMA-OMSS annotated medical staff bylaws that are available to AMA members.

In addition to serving as MSV’s representative to the Organized Medical Staff Section of the AMA, Dr. Monahan serves as a member of Virginia's delegation to the AMA along with the following MSV members:

Carol Shapiro, M.D., M.B.A. (Chair)
Randolph Gould, M.D., FACS (Vice-Chair)
H. Christopher Alexander III, M.D., FACP
Claudette Dalton, M.D.
Mitchell Miller, M.D., FAAFP
Hazle Konerding, M.D.
David A. Ellington, M.D.
Thomas W. Eppes, M.D.
Craig L. Hensle, M.D.
Edward G. Koch, M.D.
Russell C. Libby, M.D., FAAP
Bhushan H. Pandya, M.D.
Sterling Ransone, M.D., FAAFP