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CMS Backpedals on Medical Staff Director Requirement

Thursday, July 5th, 2012

In May 2012, CMS issued final regulations containing new conditions of participation requirements for hospitals. One new requirement that was included in final regulations was the requirement that one or more members of the medical staff be included on a hospital’s governing body. The medical staff director requirement had not been included in previous proposed regulations and took the industry by surprise when it was included in the final regulations. The requirement was scheduled to go into place effective July 16, 2012.

 Several organizations, including the American Hospital Association, objected strongly to CMS issuing the final rule without the opportunity for stakeholders to provide any input into this new requirement.

 In a recent release from CMS, it appears that CMS may be backpedaling on this requirement. However, a June 15, 2012 memorandum from CMS to State Survey Agency Directors instructs state survey agencies not to attempt to assess compliance with this requirement or cite deficiencies without receiving further instructions from CMS. The memorandum also provides that accrediting organizations are not required to revise their standard or survey processes until CMS has addressed the issue completely.

 At least for now, the requirement that a medical staff member be included on the Board of Directors of a hospital need not be implemented. Stay tuned for further releases from CMS on this issue. It appears possible that CMS will reverse its decision on this issue in view of the regulatory deficiencies used to adopt the requirement.

John H. Fisher

Health Care Counsel
Ruder Ware, L.L.S.C.
500 First Street, Suite 8000
P.O. Box 8050
Wausau, WI 54402-8050

Tel 715.845.4336
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