Health Regulatory and Strategic Counseling

Governance: Our attorneys stay abreast of the latest approaches to governance strategies, including The Joint Commission’s approach to hospital leadership as a three-part process that involves the board, medical staff, and the administration. Our attorneys analyze the very important role of governance in the oversight of your organization’s activities, including compliance with myriad laws and regulations that face health care organizations today. Additionally, we advise boards on the potential liabilities faced by health care providers’ leaders in the event of any compliance issue. We counsel on board structure and restructuring, including the development of corporate bylaws, to facilitate governance in both stand-alone health care entities and complex multi-corporate health systems.

We assist in the development of policies to guide board activity, including the board obligations made necessary by the Sarbanes-Oxley Act of 2002, conflict-of-interest policies, policies to comply with the Internal Revenue Service’s intermediate sanction regulations, and codes of conduct for leaders. We also provide legal advice to boards on their fiduciary obligations and legal duties to the organizations they serve, including the proper exercise of their fiduciary duties to oversee financial performance, compliance, and quality as well as on a broad range of legal issues that confront governance in today’s complex health care environment.

Licensure, Certification, and Accreditation Counseling: Our Health Care attorneys continually monitor developments in health care laws affecting hospitals and other providers. We provide you with up-to-the-minute notifications of new developments, whether through our Legal News Alerts, Friday Focus Web Conference Series, or teleconferences. Our attorneys advise on compliance with health care standards on a variety of issues, including The Joint Commission; National Committee for Quality Assurance (NCQA); Medicare and Medicaid certification and licensing; medical staff bylaws, rules and regulations, and policies; Health Care Quality Improvement Act of 1986; National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank; practitioner credentialing; statements of deficiencies and plans of correction issued by federal and state regulatory agencies; admission agreements; arbitration agreements; policies and procedures; codes of conduct; patient transfer and discharge; informed consent; and mandatory reporting requirements. 

Medical Staff Structures, Peer Review, Quality, and Medical Staff Counseling: Our attorneys are adept in assisting in the management of all medical staff matters. We have significant experience in the creation and structuring of medical staffs and managing relationships among hospital medical staffs, administration, and governing bodies, including the drafting of medical staff bylaws, rules, and regulations, and medical staff policies and procedures. Foley has represented both hospital and physician clients in medical staff hearing and appeal procedures involving disputes and litigation, when necessary, related to credentialing and peer review, and advice on National Practitioner Data Bank reporting issues.

With the many legal issues medical staffs face today, we also focus on ensuring compliance with the applicable state and federal laws and with the accreditations standards of The Joint Commission. We seek to keep you informed on emerging issues and trends involving medical staffs and are often engaged to provide education and training on a broad range of legal issues.