Section 3 .
Corrective Action
3.1 Automatic Relinquishment / Voluntary Resignation
In the following triggering circumstances , the practitioner ’ s privileges and / or membership will be considered relinquished , or limited as described , and the action shall be final without a right to hearing . Where a bona fide dispute exists as to whether the circumstances have occurred , the relinquishment , suspension , or limitation will stand until the MEC determines it is not applicable . The MEC will make such a determination as soon as feasible . The Chief of Staff , with the approval of the CMO or CEO , may reinstate the practitioner ’ s privileges or membership after determining that the triggering circumstances have been rectified or are no longer present . If the triggering circumstances have not been resolved within sixty days , the practitioner will have to reapply for membership and / or privileges . In addition , further corrective action may be recommended in accordance with these bylaws whenever any of the following actions occur :
3.1.1 Licensure
a . Revocation and suspension : Whenever a practitioner ’ s license or other legal credential authorizing practice in this state is revoked , suspended , expired , or voluntarily relinquished , medical staff membership and clinical privileges shall be automatically relinquished by the practitioner as of the date such action becomes effective .
b . Restriction : Whenever a practitioner ’ s license or other legal credential authorizing practice in this state is limited or restricted by an applicable licensing or certifying authority , any clinical privileges that the practitioner has been granted at this hospital that are within the scope of said limitation or restriction shall be automatically limited or restricted in a similar manner , as of the date such action becomes effective and throughout its term .
c . Probation : Whenever a practitioner is placed on probation by the applicable licensing or certifying authority , his or her membership status and clinical privileges shall automatically become subject to the same terms and conditions of the probation as of the date such action becomes effective and throughout its term .
3.1.2 Medicare , Medicaid , Tricare , or other federal programs : Whenever a practitioner is sanctioned or barred from Medicare , Medicaid , Tricare , or other federal programs , medical staff membership and clinical privileges shall be considered automatically relinquished as of the date such action becomes effective . Any practitioner listed on the United States Department of Health and Human Services Office of the Inspector General ’ s List of Excluded Individuals / Entities will be considered to have automatically relinquished his or her privileges .
MEDICAL STAFF Investigations , Corrective Action , Hearing and Appeal Plan
Page 4