Medical Staff Bylaws: Meeting New Medicare Conditions of Participation and Joint Commission Requirements
Complying With CMS Changes and Updating Hospital Governance Documents
Recording of a 90-minute CLE webinar with Q&A
This CLE webinar will prepare healthcare counsel to advise and guide healthcare providers and hospitals on ensuring medical staff bylaws comply with Joint Commission standards, Centers for Medicare and Medicaid Services (CMS) conditions of participation, and federal and state law. The panel will also review the impact of healthcare reform on medical staff governance.
Outline
- Introduction
- Recent regulatory and accreditation changes that affect medical staff bylaws, rules and regulations, and policies
- Overview of changes
- The Joint Commission
- CMS
- Recommended changes to bylaws, rules and regs, and policies
- MS.01.01.01 changes—advanced tips beyond just the basics people have heard before
- Telemedicine
- Effect on expiration of covering provider authenticating verbal order grace period
- Including NPs and PAs in bylaws and bylaw process
- Recent experiences with enforcement
- MS.01.01.01
- Anticipation on enforcement of authenticating verbal order if grace period expires
- Telemedicine
Benefits
The panel will review these and other key questions:
- What processes, roles and responsibilities must be included in medical staff bylaws?
- What potential pitfalls could be encountered in amending and approving revised bylaws—and what strategies can hospitals employ to overcome them?
- What impact have the revised Conditions of Participation had on medical staff bylaws?
Faculty

Richard D. Barton
Partner
Procopio Cory Hargreaves & Savitch
Mr. Barton has represented health care providers and health systems for over 30 years. As trial counsel, he has tried... | Read More
Mr. Barton has represented health care providers and health systems for over 30 years. As trial counsel, he has tried and arbitrated over 100 matters on behalf of health systems, hospitals, physician groups, and individual providers in business, class action, professional liability, fraud and abuse, and administrative matters in both Federal and State court. Mr. Barton has also been retained by numerous hospitals and health systems to serve in a consultative role to assist hospitals, medical staffs and physician groups in their oversight responsibilities.
CloseScott C. Gardner
Atty
Buerger Moseley & Carson
Mr. Gardner’s practice focuses on healthcare law and the representation of hospital corporations. His... | Read More
Mr. Gardner’s practice focuses on healthcare law and the representation of hospital corporations. His clients include for-profit hospital systems with facilities throughout the country. Mr. Gardner counsels his clients on peer review, credentialing, HIPAA, EMTALA, Joint Commission accreditation, board and medical staff bylaws, Anti-Kickback Statute/Stark compliance and various contractual issues. He has completed numerous physician due process hearings and frequently participates in medical staff committee and board meetings.
CloseAlma L. Saravia
Shareholder
Flaster/Greenberg
Ms. Saravia concentrates her practice in healthcare law. Her clients include physicians, nurses, chiropractors,... | Read More
Ms. Saravia concentrates her practice in healthcare law. Her clients include physicians, nurses, chiropractors, hospitals, medical staff, nursing homes and other healthcare organizations. She counsels practitioners on licensure and disciplinary matters, including those before the Board of Medical Examiners, where she served as member from 1992 to 1994. Ms. Saravia is a frequent lecturer and author. Her recent speaking engagements include a presentation to the Camden County Bar Association, where she spoke on "Representing Physicians in Today's Legal Quagmire".
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