1. An application for membership satisfying all requirements outlined in the Medical Staff Bylaws must be completed. The application must be completed in its entirety, with all of the appropriate signatures and supporting documentation prior to submission to the Medical Staff/Credentialing Services.
2. The contents of the application will be reviewed to ensure that the entire application (including requested attachments) is complete. It is the applicant’s burden of responsibility to supply the documents or information requested without exception.
3. Contents of a Completed Application
- An application is complete when there are no blank spaces or unanswered questions, and the release is signed.
- Applicant has returned completed delineation of privilege forms. These forms should be checked off appropriately, signed, and dated.
- Applicant has included a copy of his current DEA, current medical license, current malpractice insurance (showing applicant’s name and the insurance expiration date), and state controlled substance license (if applicable).
- Applicant has returned additional forms to the facility. (i.e. Acknowledgment of Medicare/Champus Penalties, Pharmacy Physician Information, Medical Records Physician Information, Managed Care Information)
- Any application received void of any of the information listed above will be returned directly to the applicant, outlining deficiencies and will not be processed until all requested information is provided. If an application has to be returned to an applicant, it generally constitutes a 3-4 week delay in the credentialing process.
- If the application is not complete within 50 days of the initial request for medical staff membership, a letter will be sent to the applicant outlining what is still missing from the application. If the missing documents are not provided within 30 days, the applicant will be considered as not wanting staff privileges. This letter will be carbon copied to the CEO of this facility as a status report on that individual. The Medical Staff Bylaws put the burden of proof on the applicant and often, it is necessary to have the applicant aid us in obtaining the required information.
4. Completed Application
- Once the application is completely verified, the entire credentials packet is submitted to the Medical Executive Committee for review. The Medical Executive Committee is legally responsible for a thorough review of all credentials.
- Clinical privilege delineation requests must be submitted with the application and should be appropriate to the type of care or services provided at this facility. A request for each specific privilege must be made and the clinical privilege delineation form must clearly identify each privilege granted.
- The Medical Executive Committee determines the outcome of privilege requests beyond the scope of training, skill and/or expertise of the applicant. When uncertain, the Medical Executive Committee should request further documentation of adequate training or experience. The medical staff applicant is contacted right away regarding requests beyond the scope of services offered at the facility and the applicant ultimately should withdraw the request.
- The Governing Body is ultimately accountable for persons given medical staff privileges. Once recommended by the Medical Executive Committee (MEC), the credentials file must have final approval from the Governing Body. Board approval is required for all medical staff applicants.
5. Reappointment and Appointment
- After completing a 1-year Provisional staff appointment, re-appointment to the Medical Staff is handled biannually, or every two years. A reappointment application will be sent to medical staff members no later than 6 months prior to their reappointment date. The reappointment date will be based on the date that the physician became a member of your medical staff. Clinical delineation requests must be reviewed at the time of reappointment, and any changes in privilege must be documented. The application for reappointment is somewhat modified, omitting education information that does not change. Quality review and work performance information on all applicants for re-appointments are reviewed for the past two years during the reappointment process.
- Medical Staff/Credentialing Services will process each applicant for appointment or reappointment through the National Data Bank and will act appropriately upon information received. Credentialing activity and legal matters as required by law will be reported from LMS Hospitals to Credentialing then to the Data Bank. Such transactions will be accomplished on forms specified by the Data Bank.
- Peer Review is required on the local level at both appointment and reappointment. During the application process for appointment to the medical staff, before the applicant has practiced at this facility, 3 letters of reference from practitioners at other facilities may accomplish their peer review. At reappointment, a profile of in-house activities is reviewed, approved by medical staff members with authority to review such and at least one recommendation/reference must be provided, preferably from another member of this facility’s medical staff. A peer practicing at another facility may be the reference but must be at least a member of the same specialty.
- Health status, lawsuit activity, medical malpractice insurance information, and the status of all appropriate licenses must also be furnished at reappointment. All other criteria described in the medical Staff Bylaws must be met as well. Administrators and Medical Staff Coordinators are to read and be thoroughly familiar with the provisions of the Medical Staff Bylaws.
- The Medical Staff and the Governing Board may approve candidates for full privileges, modified privileges from those requested, or no privileges after a thorough review and study of the applicant’s credentials file either during the initial appointment process or at reappointment as deemed appropriate. Action may be taken between appointments if necessary by following the processes outlined in the medical staff Bylaws.
- The Medical Staff Appointment Action sheet is to be signed by the President of the Medical Staff and Chairman of the Executive Committee. A memo then needs to be done, naming the approved physicians and sent to the Corporate Office for Governing Board signatures (President of the Governing Board/CEO of LMS). The President of the Governing Board’s Signature must be on the Medical Staff Appointment action sheet.
- After board approval, a letter of appointment is sent to the physician from the CEO. The letter of appointment is traditionally generated from the Administrator’s/CEO’s office. However, it may generate from the Acuity Corporate office as an alternative. If the MEC does not recommend privileges on an applicant, the applicant must be notified including his/her right to a fair hearing and the reason(s) for being denied.
6. Updates for Expired Medical Licenses, DEA, Malpractice Insurance, and Controlled Substance Licenses.
Please contact Jodi Rusinovich, Business Office Manager / Credentialing at (304) 919-4306 to request medical staff membership application.