CMS SOM App. A, Tag A-0348

certified hospitals and the system elects to have a unified and integrated medical staff for

its member hospitals, after determining that such a decision is in accordance with all

applicable State and local laws, each separately certified hospital must demonstrate

that:….

Interpretive Guidelines §482.22(b)(4)

A hospital that is part of a system consisting of multiple separately certified hospitals may use a

single unified and integrated medical staff (hereafter referred to as a “unified medical staff”) that

is shared with one or more of the other hospitals in the system. In other words, as long as the

requirements of §482.22(b)(4) are met, it is not necessary for each separately-certified hospital

within the system to have its own distinct medical staff organization and structure, including

hospital-specific medical staff bylaws, rules and requirements, hospital-specific medical staff

leadership, hospital-specific credentialing and peer review, etc. Instead, it may use one medical

staff organization and structure for multiple hospitals, so long as all of the requirements of this

section are met. However, separately certified hospitals which share a single unified and

integrated medical staff must also share a system governing body, in accordance with the

provisions of §482.12, since only one governing body may carry out the governing body’s

medical staff responsibilities for a unified medical staff.

Note that a multi-campus hospital that has several inpatient campuses that are provider-based,

remote locations of the hospital is not a multi-hospital system. A multi-campus hospital is one

certified hospital, not several separately certified hospitals. A multi-campus hospital may not

have separate medical staffs at each campus, since each hospital must have no more than one

medical staff. A multi-campus hospital with one medical staff separate from that of other

certified hospitals is not employing a unified medical staff as that term is used in this regulation.

However, a multi-campus hospital that is part of a hospital system consisting of multiple

separately certified hospitals may share a unified medical staff with other separately certified

hospitals within the system.

It should also be noted that a hospital system that includes certain types of hospitals, i.e.,

Hospitals-within-Hospitals or Hospital Satellites, that are being paid under a Medicare payment

system other than the Hospital Inpatient Prospective Payment System (IPPS) might jeopardize

the Medicare payment status of those excluded hospitals if it owns both the tenant and host

hospitals and uses a unified medical staff for both. This is the case even if the requirements of

§482.22(b)(4) are met. However, surveyors do not assess compliance with or enforce the

Medicare payment regulations that govern Hospitals-within-Hospitals or Hospital Satellites.

When granting practitioners privileges to provide patient care, a hospital’s governing body must

specify those hospitals in the system where the privileges apply, since, in addition to the

qualifications of individual practitioners, the services provided at each hospital must be

considered when granting privileges. For example, psychiatric hospitals do not offer surgical

services, labor and delivery services, nuclear medicine, etc., so it would not be appropriate for

practitioners practicing in these areas to hold privileges at psychiatric hospitals in a multi-hospital system that uses a unified medical staff. Likewise if a multi-hospital system covers a

wide geographic area, many of its practitioners may have no interest in practicing on site at

hospitals that are distant from their usual practice location(s). In addition, in order for the

acceptance or opt-out provisions of §482.22(b)(4)(i) and (ii) to be workable, privileges must be

granted on a hospital-specific basis to practitioners who actually practice or are likely to practice

at the hospital.

The governing body in a multi-hospital system must elect to exercise this option. Since a

number of hospital systems interpreted the Medical Staff CoP to permit a unified and integrated

medical staff prior to publication of the final rule at §482.22(b)(4) on May 12, 2014 or its

effective date on July 11, 2014, the existence of a unified medical staff prior to July 11, 2014 is

considered evidence of the hospital’s governing body’s election of this option.

• This does not relieve the governing body of the responsibility to conduct a review

of all applicable State and local laws, including regulations, and make a

determination that use of a unified medical staff that is shared by multiple

hospitals does not conflict with those laws. The hospital must maintain

documentation of this determination by its governing body.

• Nor does it relieve the governing body of the obligation to inform the medical

staff of the right to vote to opt out of a unified medical staff arrangement. (See

discussion of §482.22(b)(4)(ii), which requires notification of all members of this

right. Failure to comply would be cited under the tag for §482.22(b)(4)(ii).)

If a hospital is part of a multi-hospital system that wishes to establish a unified medical staff for

some or all of its separately certified hospitals after the July 11, 2014 effective date of the final

rule at §482.22(b)(4), then the hospital’s system governing body must document in writing its

decision to elect to use the unified medical staff option, conditioned upon acceptance of a

unified medical staff by the hospital’s medical staff in accordance with §482.22(b)(4)(i).The

governing body must also document its determination that such election does not conflict with

State or local laws, including regulations.

Surveyors are not expected, as part of their assessment of compliance with the Medicare CoPs, to

evaluate whether the governing body’s determination of compliance with State and local law is

accurate. This would be handled by the appropriate State or local authorities, or, if the State

Survey Agency is the appropriate authority, under its State licensure or other authority and not as

part of a Federal survey.

Survey Procedures §482.22(b)(4)

• Ask the hospital and medical staff leadership if the hospital is part of a multi-hospital

system of separately certified hospitals. If yes, ask if the hospital also shares its

governing body and medical staff with one or more other separately-certified

hospitals in the system.

• If yes:

• Does the use of the unified medical staff predate July 11, 2014? If yes, ask for

documentation of the governing body’s determination that use of a unified

medical staff does not conflict with State or local law.

• Did the use of the unified medical staff start after July 11, 2014? If yes, ask

for documentation of the governing body’s decision to elect use of a unified

medical staff and of its determination that use of a unified medical staff does

not conflict with State or local law.

• Can the hospital produce documentation that practitioners who practice at the

hospital have been granted privileges by the hospital’s governing body that

specify the practitioner’s privileges apply to specific hospital(s), which

include the hospital being surveyed?