Requirements for a fair hearing process

CMS requires that medical staffs must have a policy for fair hearing and appeal. An applicant or an individual holding a medical staff appointment is entitled to request a hearing when the MEC or the board has made an unfavorable recommendation regarding staff membership or privileges.

Unfavorable recommendations include the following:

  • Denial of initial medical staff appointment
  • Denial of medical staff reappointment
  • Revocation of medical staff appointment
  • Denial of requested initial clinical privileges
  • Denial of requested additional clinical privileges
  • Decrease of clinical privileges
  • Suspension of clinical privileges (other than precautionary suspension)
  • Imposition of mandatory concurring consultation requirement

The medical staff bylaws definition of the fair hearing process must include the following:

  1. The process for scheduling hearings and appeals
  2. The process for conducting hearings and appeals
  3. The composition of the fair hearing panel

The fair hearing panel should not include any individual who is in direct economic competition with the affected person or who is professionally associated with or related to the affected individual. The panel may consist of medical staff members who have had no involvement in the matter and may consist of physicians not connected with the hospital in any way.

Source: Credentialing Resource Center Encyclopedia

Did you know that Credentialing Resource Center Platinum and Platinum Plus members have access to a credentialing encyclopedia?  This resource is an on-the-go reference packed with easy-to-digest credentialing and privileging terms, definitions, and guidance to assist MSPs and medical staff leaders in their daily tasks. To access the encyclopedia, click here. To learn about Credentialing Resource Center memberships, click here.