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CMS Puts Hold on Change to the Hospital Conditions of Participation

June 22, 2012—In response to concerns raised by the AAMC and other associations, the Centers for Medicare and Medicaid Services (CMS) issued a June 15 memorandum that puts on hold a change to the hospital conditions of participation (CoPs) that would have been effective July 16. 

The hold affects the requirement that hospitals’ governing bodies include one or more members of the medical staff, which could conflict with other federal, state, or local laws.  The memorandum indicates that CMS will “reconsider this requirement in future rulemaking.” In the meantime, surveyors are instructed not to issue citations related to this provision.

Stakeholders also raised concern that language in the preamble to the final regulation indicates that a multi-hospital system would be required to have a separate medical staff for each hospital.  While this issue was not addressed in the memorandum, the CMS noted that it is “working diligently to develop interpretive guidance” for the other CoP changes that were to be effective July 16.  Until such guidance is issued, it is not possible for surveyors to assess compliance with the CoP requirements.


Ivy Baer, J.D., M.P.H.
Senior Director and Regulatory Counsel
Telephone: 202-828-0499


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Washington Highlights, a weekly electronic newsletter, features brief updates on the latest legislative and regulatory activities affecting medical schools and teaching hospitals.

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Jason Kleinman
Sr. Legislative Analyst, Govt. Relations
Telephone: 202-903-0806