WES MOORE, Governor Ch. 358
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Chapter 358
(Senate Bill 258)
AN ACT concerning
Hospital Credentialing – Reappointment Process for Physician Staff –
Modification
FOR the purpose of requiring that the credential reappointment process for physician staff
included in certain minimum standards for hospitals licensed in the State be
conducted in accordance with standards of the accreditation body that accredits a
hospital, rather than with a certain frequency; and generally relating to the
credentialing process for hospital physician staff.
BY repealing and reenacting, without amendments,
Article – Health – General
Section 19–319(e)(2) and (7)
Annotated Code of Maryland
(2019 Replacement Volume and 2022 Supplement)
BY repealing and reenacting, with amendments,
Article – Health – General
Section 19–319(e)(4)
Annotated Code of Maryland
(2019 Replacement Volume and 2022 Supplement)
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND,
That the Laws of Maryland read as follows:
Article – Health – General
19–319.
(e) (2) As a condition of licensure, each hospital shall:
(i) Establish a credentialing process for the physicians who are
employed by or who have staff privileges at the hospital; and
(ii) Use the uniform standard credentialing form as the initial
application of a physician seeking to be credentialed.
(4) (I) The Secretary shall, by regulation and in consultation with
hospitals, physicians, interested community and advocacy groups, and representatives of
the Maryland Defense Bar and Plaintiffs’ Bar, establish minimum standards for a
credentialing process which shall include:
Ch. 358 2023 LAWS OF MARYLAND
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[(i)] 1. A formal written appointment process documenting the
physician’s education, clinical expertise, licensure history, insurance history, medical
history, claims history, and professional experience[.];
[(ii)] 2. A requirement that an initial appointment to staff not be
complete until the physician has successfully completed a probationary period[.]; AND
[(iii)] 3. [A] SUBJECT TO SUBPARAGRA PH (II) OF THIS
PARAGRAPH , A formal, written reappointment process to be conducted [at least every 2
years] IN ACCORDANCE WITH STANDARDS OF THE ACC REDITATION BODY THAT
ACCREDITS A HOSPITAL.
(II) The reappointment process ESTABLISHED UNDER
SUBPARAGRAPH (I)3 OF THIS PARAGRAPH shall document the physician’s pattern of
performance by analyzing:
1. Claims filed against the physician;
2. Data dealing with utilization, quality, and risk;
3. Clinical skills;
4. Adherence to hospital bylaws, policies, and procedures;
5. Compliance with continuing education requirements;
6. Mental and physical status; and
7. The results of the practitioner performance evaluation
process under subsection (i) of this section.
(7) If a hospital fails to establish or maintain a credentialing process
required under this subsection, the Secretary may impose the following penalties:
(i) Delicensure of the hospital; or
(ii) $500 per day for each day the violation continues.
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect
October 1, 2023.
Approved by the Governor, May 3, 2023.