Credentialing & Privileging

Ask the expert: Would denying privileges due to lack of board certification violate the CoPs?

Credentialing Resource Center Connection, June 18, 2009

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Q: Can a hospital require board certification for medical staff membership and privileges, even though the Medicare and Medicaid Conditions of Participation (CoP) specify that “the governing body must ensure that under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent solely upon certification, fellowship, or membership in a specialty body or society”? Would the CoP be violated if the absence of board certification were the sole basis for denying medical staff membership and privileges?

A: Many hospitals nationwide require board certification/admissibility as a requirement of medical staff membership. Accordance of staff membership means that the governing board cannot place a physician on staff simply because he or she is certified, but the CoPs are silent on the issue of denying a physician medical staff appointment solely because he or she is not certified. In several states, the licensure statute or state attorney is more specific on this issue, so organizations should check their state’s law on this issue.

This week’s Q&A is from Core Privileges for Physicians: A Practical Approach to Developing and Implementing Criteria-Based Privileges, Fourth Edition, by Wendy Crimp, RN, BSN, MBA, CPQH; Sally J. Pelletier, CPMSM, CPCS; Vicki L. Searcy, CPMSM; and Mark Smith, MD, MBA, FACS.



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