Legal Updates
Updates regarding CMS and Joint Commission 3-year reappointment terms, Current as of 12/15/2022
This does not come from state law. It comes from the Medicare Conditions of Participation for Hospitals. The reappointment cycle and required timeframes will depend on the hospital’s accrediting body.
42 C.F.R. 482.22(a)(1) (Medicare CoP) states that the hospital must have an organized medical staff with bylaws approved by the governing board that is the responsible for the quality of the medical care provided to patients at the hospital. The medical staff must be comprised of physicians (MDs and DOs) and can also include non-physician practitioners. The medical staff must identify various categories of membership and must periodically conduct appraisals of members.
The Medicare CoP does NOT specify the maximum appointment period or how often the appraisals must be done. Of course, if state law has a requirement, then we must go with state la.w Many states adopt a 2-year timeframe. As you note below, Florida law is silent.
In order to participate in Medicare, the hospital must be accredited. The accrediting bodies adopt standards that are based off of the Medicare CoPs. The Joint Commission is one of the most popular accrediting bodies for hospitals. Its standard is a maximum 2-year appointment term and references 42 C.F.R. 482.22(a)(1) as the basis for this timeframe.
I would recommend that each medical staff office check the particular standards proscribed by its accrediting body. During COVID, we certainly had waivers for reappointment terms. And there may be changes to the most recent Joint Commission standards that I can access (e.g. increased to 3 years). I am not sure about HFAP or DNV.
It’s always best to give your medical staff bylaws a periodic “look over” to make any updates, clean up amendments, etc. Now is the perfect time to schedule a “check up” as we head into the new year, come out of the pandemic, and need to evaluate for recent changes, updates, new services (e.g. telemedicine), etc.
AMANDA L. WAESCH
Vice President
Brennan, Manna Diamond
