This document summarizes a webinar on licensing and privileging in healthcare law. It discusses the various layers of regulation that physicians face, including state licensing boards, specialty boards, hospitals, insurers, employers and Medicare/Medicaid. It covers the process of obtaining licenses and board certificates. It also explains hospital medical staff structure and privileges, the credentialing process, the Health Care Quality Improvement Act and protections it provides, and the potential consequences physicians face if allegations of improper practice occur.

1. Fundamentals in Healthcare Law Curriculum
2021 – 2022 WEBINAR SERIES
PA R S O N S B E H L E . C O M
N AT I O N A L E X P E R T I S E . R E G I O N A L L AW F I R M .
Licensing and Privileging
Wednesday, February 16, 2022

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3. 3
Legal Disclaimer
This webinar is based on available information as of February 16,
2022, but everyone must understand that this webinar is not a
substitute for legal advice. This presentation is not intended and will
not serve as a substitute for legal counsel on these issues.

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Presenters
• Lee Radford
208.522.5252
lradford@parsonsbehle.com
• Jameson Rammell
208.522.5227
jrammell@parsonsbehle.com

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Layers of Regulation
• Physicians and health care providers are regulated through several
layers of oversight and regulation:
◦ State Licensing Board
◦ Specialty Boards
◦ Hospital Medical Staff
◦ Insurance Networks and Provider Organizations
◦ Employer or Physician Group or Practice
◦ Medicare / Medicaid
◦ Courts

6. Licensing and Board Certificates

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Licensing
• Health Profession
Licensing (State of Idaho)
◦ Athletic Trainers
◦ Chiropractic Physicians
◦ Dentists
◦ Dietitians
◦ Medicine
 Physicians
 Physician Assistants
◦ Naturopathic
◦ Nursing
 Nurse Practitioners
◦ Occupational Therapy
◦ Optometry
◦ Pharmacy
◦ Physical Therapy
◦ Podiatry
◦ Respiratory Therapy
◦ Speech, Hearing and Communication
◦ Midwifery
◦ Counselors / Therapists
◦ Others

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Licensing Statutes
• State licensing statutes generally include several components:
◦ Prohibition on practice without license
◦ Board of licensed professionals to govern licensing and investigations
◦ Procedures for issuance of licenses
◦ Grounds for discipline
◦ Procedures for investigation and discipline

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Board Specialization and Certificates
• In addition to a license
to practice in a state,
physicians can obtain
board certificates
showing their
specialties in specific
areas, such as:
◦ Allergy and Immunology
◦ Anesthesiology
◦ Colorectal Surgery
◦ Dermatology
◦ Emergency Medicine
◦ Family Medicine
◦ General Surgery
◦ Internal Medicine
 Cardiovascular
Disease
 Critical Care Medicine
 Infectious Disease
 Pulmonary Disease
 Rheumatology
 Sleep Medicine
◦ Obstetrics &
Gynecology
◦ Opthalmology
◦ Orthopaedic Surgery
◦ Otolaryngology
◦ Pathology
◦ Plastic Surgery
◦ Preventive Medicine
◦ Psychiatry and
Neurology
◦ Radiation Oncology

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Board Certificates and Discipline
• In addition to maintaining a license in the state, most physicians
must also keep up the physician’s certificate with the physician’s
certifying board.
◦ This requires periodic education, testing, and qualification procedures.
◦ Certifying boards also follow their own disciplinary procedures.

11. Hospital Privileging, Credentialing,
and Medical Staff Issues

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Medical Staff
• The Medical Staff of a hospital is a unique relationship
◦ Mutually beneficial
 Hospitals need Providers
 Providers need Hospitals
◦ Not an employment relationship, unless physician employed by hospital
◦ Essentially a “license” to use healthcare facilities
• Employed physicians at a hospital are governed both by:
◦ Medical staff organization and bylaws
◦ Hospital employment policies
• The Medical Staff of a hospital is governed by:
◦ Bylaws and policies and related documents
◦ Medicare Conditions of Participation (COPs)
◦ Accreditation requirements by accrediting crganizations

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Medical Staff Bylaws
• What is in the Medical Staff Bylaws?
◦ Governance
 Governing Board
 Medical Staff
◦ Credentialing: Appointment to Medical Staff
 How to apply and be appointed to Medical Staff
 Categories of Medical Staff
◦ Allied Health Professionals (NPs, PAs, etc.)
◦ Privileges: Scope of Clinical Practice Allowed
◦ Corrective Actions
◦ Hearing and Appellate Review
◦ Code of Conduct
◦ Medical Staff Organization
 Meetings
 Officers
 Committees
 Departments

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Credentials and Privileges
• Credentialing
◦ Appointment to Medical Staff
 The process of verifying a physician’s credentials and verifying that the physician is licensed to practice by the state.
• Privileging
◦ Defines the physician’s scope of practice relating to patient care.
◦ Types of privileges
 Admitting privileges
– allow a physician to admit a patient to the hospital and visit the patient
– do not necessarily allow the physician to treat the patient
 Surgical privileges
– allow a physician to perform surgeries or treat the patient
– based on experience and clinical knowledge and board certifications

15. Health Care Quality Improvement
Act

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Health Care Quality Improvement Act
• Helps medical staffs discipline themselves.
◦ Provides immunity from civil litigation for good faith efforts to discipline members of a
medical staff.
• Provides national database of competence issues of individual
physicians.
◦ Prevents disciplined physicians from moving from state to state to avoid disciplinary
procedures.

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Health Care Quality Improvement Act
• Hospital must both report and seek information from the National
Practitioner Data Bank (“NPDB”):
◦ Must report “adverse actions” taken against a physician
 Termination or restriction of clinical privileges
 Relinquishment of privileges pending or in lieu of investigation
◦ Must query the NPDB
 When the physician initially applies
 At least every two years thereafter

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Health Care Quality Improvement Act
• If requirements are met, the HCQIA provides the hospital and the
medical staff protection against antitrust and most other types of
liability arising from discipline of providers:
◦ Does not protect against injunctive relief or civil rights claims
◦ Rebuttable presumption that HCQIA standards are met
◦ Does not create a private right of action
◦ Medical staff bylaws should be drafted to obtain HCQIA protection

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Health Care Quality Improvement Act
• Provides immunity from liability for:
◦ “Professional Review Activity”
 “an activity of a healthcare entity with respect to an individual physician –
– To determine whether the physician may have clinical privileges with respect to, or membership in, the
entity;
– To determine the scope or conditions of such privileges or membership; or
– To change or modify such privileges or membership.”
42 U.S.C. § 11151(10).

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Health Care Quality Improvement Act
• To be entitled to HCQIA protection, the professional action must be
taken:
◦ “in the reasonable belief that the action was in the furtherance of quality health care”
◦ “after a reasonable effort to obtain the facts of the matter”
◦ “after adequate notice and hearing procedures are afforded to the physician involved or after
such other procedures as are fair to the physician under the circumstances”
◦ “in the reasonable belief that the action was warranted by the facts known after the exercise
of such reasonable effort to obtain facts and after” the adequate procedures
42 U.S.C. § 11112.

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Cascade of Discipline
• When a physician faces allegations of improper practice, it will often
result in a cascade of disciplinary actions at different levels, such as:
◦ State Licensing Board
◦ Physician Specialty Board
◦ Hospital Medical Staff
◦ Insurance Networks and Organizations
◦ Employer or Physician Group or Practice
◦ Medicare / Medicaid
◦ Courts (Malpractice Litigation)

22. Defending Against Disciplinary
Actions

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Thank You
• Lee Radford
208.522.5252
lradford@parsonsbehle.com
• Jameson Rammell
208.522.5227
jrammell@parsonsbehle.com