Legal Issues Concerning Hospital Privilege Denials

Posted Date: June 5th, 2014 | Categories: Credentialing

Under Ohio law, the governing body of every hospital has the duty to establish standards and procedures to be applied by the hospital and its medical staff in considering and acting upon applications for medical staff membership and professional privileges. 

If you have questions or concerns regarding hospital privileges please contact us at (614) 545-9998. 

Overview of Hospital Privileges 

  • Hospitals have a formal application process for physicians seeking medical staff privileges, which include verifying the credentials of the applicant physician. 
  • Hospitals may not discriminate against qualified providers based upon the applicant’s licensure, whether licensed to practice medicine, osteopathic medicine, podiatry, dentistry or psychology. 
  • If a physician believes he/she is being discriminated based upon licensure, he /she may apply to the court of common please for temporary or permanent injunctions against the hospital. 
  • Only a physician, dentist, or podiatrist who is a member of the medical staff may admit a patient to that hospital. It is the responsibility of the admitting dentist or podiatrist to make arrangements with a physician who is a member of the medical staff to be responsible for the patient’s treatment outside of the dentist’s or podiatrist’s scope of practice. 
  • Hospitals should have a privileging process that is fair and grants privileges based on documented training, experience and current clinical competence. Privileging based on other factors are contrary to the written standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). 
  • Hospital privileges establish the scope of services the physician is authorized to perform within the hospital and the criteria must be the same for all applicants.  For example, criteria for electrocardiogram interpretation, pneumonia management or colonoscopy must be the same for all physicians in the hospital, regardless of departmental affiliation or specialty. 


  • Physicians (MD or DO) may be granted full admitting privileges based upon their qualifications and experience. 


  • A dentist is responsible for making arrangements with a DO or MD member of the staff to perform the required initial physical examination and to be responsible for all treatment outside the scope of the dentist’s license during the patient stay. 


  • Podiatrist may be appointed to hospital staffs and may admit for treatment consistent with his/her scope of practice. If medical treatment outside the scope of the practice of podiatry becomes necessary during the hospitalization, the podiatrist must make arrangements with a physician (MD or DO) to be responsible for that treatment. 


  • Psychologists may be appointed to hospital staffs but do not have the privilege to admit patients.  A further limitation on staff appointment is whether or not the hospital provides or permits the provision of diagnostic or treatment service for mental or emotional disorders or any other service that may legally be performed by a licensed psychologist. 

Nurse Midwives 

  • A nurse-midwife may be granted the clinical privilege to provide maternity services under the direction and supervision of a physician-member of the medical staff.

 If you have additional questions regarding the contents of this section, please contact the Jones Law Group at (614) 545-9998. 

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