Defining fair hearings and appeals in medical staff bylaws

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

Unfavorable recommendations include:

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

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

• The process for scheduling and conducting hearings and appeals
• The composition of the fair hearing panel
• The definition of an investigation, which is an integral part of the fair hearing process

The panel should not include any individual in direct economic competition with, professionally associated with, or related to the affected person. It may consist of medical staff members who were not involved in the matter, as well as physicians who are not affiliated with the hospital in any way but who have special knowledge of the issue, provider’s specialty, procedure performed, etc.

Appeal

Within a specified number of days after receiving notice of the hearing panel’s or hearing officer’s findings and recommendation, either party may appeal the recommendation. This timeline must be outlined in the medical staff bylaws and adhered to. Through an appeal, one party asks the hearing panel or officer to reverse the recommendation.

No applicant or medical staff appointee is entitled to more than one hearing and one appeal on any matter. If the board denies initial medical staff appointment or reappointment, or limits, revokes, or terminates appointment or privileges, the bylaws may prevent that individual from applying for staff appointment or those privileges for an additional period of time. For example, the practitioner may not be allowed to apply again for three years.

The best approach to fair hearings is to avoid them if at all possible. If a hospital does need to proceed with a fair hearing, follow to the letter the process outlined in the medical staff bylaws, and involve legal counsel if there are any questions or uncertainty about how to proceed. Doing so will ensure protection for the organization and fair, unbiased treatment of the affected practitioner.