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The Medical Staff Office (MSO) is the entity responsible for credentialing of physicians and allied health professionals. Pursuant to state/federal statutes and Joint Commission on Accreditation of Health Care Organizations (JCAHO) standards, all hospitals must ensure the members of its medical staff have the training/experience to provide the services they are “privileged” to perform. Managed Care Companies (MCOs), ambulatory surgery centers, clinics, preferred physician groups and physician provider organizations (PPOs) are also required to credential their members. Most of these entities also have a Medical Staff Office to coordinate the process.
Initial Appointment: To apply for hospital privileges, you should send to the facility’s Medical Staff Office, a copy of your curriculum vitae, along with a cover letter requesting an application for membership and designating your desired specialty. You will receive a packet containing instructions and forms, including but not limited to, an application, a privilege form and a release of information authorization. Most likely, there will also be forms containing statements related to informational confidentiality and Medicare participation. The application form is lengthy and requests information pertaining to your medical education, including internship, residency and fellowship(s), special certifications, DEA, licensure, U-pin and Tax ID numbers, Board Certification(s), professional liability insurance, former employment, affiliations with other hospitals, managed care companies and professional organizations.
There will also be queries as to your experience since completing your training, your personal health as well as any prior or pending disciplinary actions and claims. You need to indicate on the privilege sheet what services/procedures you wish to perform.
You need to designate whether you want your status to be “active,” courtesy” or “consulting.” Be sure to read all the forms carefully and complete them in their entirety. Failure to do so will result in process delay.
Upon completion, the forms must be returned to the MSO, along with the specified fee. You should include a copy of all your educational certificates, special certifications, your license and DEA. Additionally, you will need to have 2-3 (depending on the requirements of the facility) prior professors or peers, other than those with whom you are associated in practice, send to the hospital, in your behalf, letters of recommendation. Finally, you must instruct your professional liability insurance carrier to send the MSO a “declaration sheet” specifying your dates/limits of coverage.
Upon receipt of your materials, the MSO will query the listed institutions, either via the internet, fax or letter, to verify that the information listed is correct. They will also query your former employers and the other facilities with whom you are/or were associated to verify accuracy and to inquires as to your performance. Queries will also be made to the National Practitioners’ Data Bank and the Medicare/Medicaid Fraud/Abuse Lists to check for disciplinary actions/claims and sanctions respectively.
Once this process is complete, your application will be reviewed by the section chief, if applicable, the department chairman, the Credentials Committee, the Executive Committee of the Medical Staff and finally the hospital’s Board of Trustees. If approved, you will receive a letter of appointment, along with a copy of the facility’s Bylaws, Rules & Regulations. They will likely include an acknowledgement form that you will need to sign and return, indicating that you have read and agree to abide by these regulations.
Once appointed, (not applicable for emergency medicine), you will be placed on the “call” schedule for your specialty. Those selecting courtesy or consulting status will likely perform “call” for the first year. If you will be active, you will remain on the “call” schedule throughout your association with the facility. You will also likely be asked to select a hospital and/or Medical Staff committee on which you would like to serve.
Your status will be “provisional” for the first year. At the end of that period, your performance will be evaluated and you will be promoted to the status of your choice: active, courtesy or consulting.
Re-appointment: Medical Staff members must be re-credentialed every 2 years.
Two to three months prior to your reappointment time, the MSO will send you a packet. The application form is shorter in that it is not necessary to obtain information regarding your training or associations prior to your current appointment. Information relative to current employment, hospital/professional organization affiliation, re-certifications, ongoing training (CMEs), professional liability insurance, disciplinary actions and claims will be requested. Again, there will be a release of information form and a privilege sheet. All forms should be timely completed and returned to the MSO, along with the specified re-appointment fee. You should attach certificates from any training you received since you appointment (or last re-appointment). Again, you should attach a copy of your current license, DEA and have your professional liability insurance carrier send a declaration sheet to the MSO. This time you will only need to have one peer send a letter to the MSO recommending your re-appointment. Be sure to timely return your materials. If you do not allow the MSO adequate time to process your application, your appointment could expire and your privileges be temporarily suspended until it has been completed.
In addition to the material you provide, the MSO will query the Quality Management Department to obtain information as to your performance in the hospital during the preceding 2 years. This will include information as to blood utilization, timely/accurate completion of medical records, committee, department, and quarterly Medical Staff meeting attendance, utilization management (cost per case, avoidable days, length of stay, etc.), risk management and peer review. Depending upon your specialty, other data such as C-section rate, surgical complication and/or postoperative infection rate may be reviewed. Checklist type evaluation sheets will be sent to the department chairmen of the other hospital where you are privileged. MSO personnel will then query the National Practitioners’ Data Bank and Medicare/Medicaid Fraud Abuse List. Once all of this information has been obtained, your section chief, if applicable, and department chairman will review all and complete a checklist evaluation form. Your re-appointment will then be forwarded to the Credentials Committee, Executive Committee of the Medical Staff and Board of Trustees. Once approved, you will receive a letter confirming your re-appointment.
Additional Privileges: If at any time you wish to perform an additional service or procedure, you should submit your request, in writing, to the MSO. You should attach the appropriate training certificates to corroborate that you are qualified to receive the new privilege. Your request will then be processed and forwarded to the section chief, if applicable, department chairman, Credentials Committee, Executive Committee of the Medical Staff and Board of Trustees. Once granted, you will receive a letter of confirmation.
Renewals: If between re-appointments your license, DEA, Board Certification or other certification renews, or you change your professional liability insurance carrier, be sure to provide the MSO with that information as soon as possible.
Disciplinary action/Claims: If you are disciplined by your regulatory Board or receive a formal notice of a medical malpractice claim (Notice of Intent, Summons and Complaint), most facilities require the MSO be immediately notified.
Resignation: Should you plan to leave the area or for some other reason wish to resign your privileges, be sure to send a letter to the MSO, advising them of your intention and the date it will take place. You should provide them with a forwarding address. If applicable, be sure to have your professional liability carrier send them a declaration sheet indicating that you have purchased “tail” or “nose” (prior acts) insurance to provide coverage for two years following the date of your resignation.
Other services: In addition to the credentialing function, the MSO serves as support personnel for the Medical Staff. With your permission, they provide information about you to other hospitals, managed care companies and other entities to which you have submitted applications for privileges. They assist the department chairmen by publishing the monthly “call” schedule. They assist the Bylaws Committee in maintaining and updating the Bylaws, Rules & Regulations. They take and maintain minutes from the section, department, Bylaws Committee, Credentials Committee, Executive Committee and quarterly Medical Staff meetings. They provide secretarial duties for the section chiefs, department chairmen, aforementioned committee chairmen and Executive Committee members. They publish a monthly calendar of Medical Staff activities. They also maintain the bulletin board in the Doctors’ Lounge and have information as to local professional organizational meetings, special hospital meetings and educational opportunities in the hospital and medical community.
When you begin your practice, visit the medical staff office at the facility to which you will be applying for privileges. They will guide you through the credentialing process and do all possible to provide assistance. They usually have an open line of communication to hospital and Medical Staff administration and are a valuable source of information. 
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