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Medical Staff and the MEC


Hospital Medical Staff and the MEC

What is 42 CFR 482.22?

42 CFR § 482.22 defines the rules for a hospital’s medical staff applicable if the hospital participates in federal programs. There must be bylaws and the “governing body” meaning the board of directors must approve the bylaws.  

What are the Basic Rules for Medical Staff?

Some of the rules and regulations for medical staff are described here.

A rule that is easy to meet but at the core of a competent medical staff is 42 CFR 482.22(a). It requires that the medical staff must be composed of doctors of medicine or osteopathy.  It is not sufficiently clear as to how the governing body of this group, the Medical Executive Committee must reflect the overall medical staff or the community.  

Our physician lawyers have identified this as a legal issue when an MEC focuses investigations on certain target groups and the target group is entitled to protections under state or federal law.

Does Medical Staff Conduct Appraisals?

The medical staff must periodically conduct appraisals of its members.  The rigor of this review is not specifically mandated and it varies greatly from hospital to hospital. A legal issue arises when a lax standard of review is the norm but a rigorous standard is (inexplicably) applied to a physician client.

Does Medical Staff Conduct Credentialing?

In the credentialing process it is the medical staff which must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of these candidates. What is often done without much detail or attention is the application of limits to scope of practice.  Not that limits are not set but there is often a lack of standards which apply to scope of practice authorizations.

Does Medical Staff Evaluate New Procedures?

A key function of medical staff is to evaluate new procedures and new technology before it is used at a hospital. The final call is made by the Governing Board but it is medical staff input that provides the science and efficacy evaluation.  

Reviewing Medical Staff before Accepting Employment/Partnership

Medical staff and MEC questions arise in the context of discipline and malpractice lawsuits. However, when you are offered a job that involves privileges at a new hospital it is worthy examining the structure and function of the hospital’s medical staff.  

Is it politically driven? 

Is it controlled by a particular group of physicians?  

What is the history of discipline of physicians at the hospital?

The Horowitz medical group advises that you conduct a careful review of the political structure of a new employment or partnership environment.  Imagine that the honeymoon is over and matters have deteriorated.  Will you be unfairly subject to "peer review"?  Unfairly suspended by the MEC pending investigation?   Is there a danger of NPDB reporting?  Due diligence is much better than damage repair!