February 19, 2026

Posted on February 19, 2026February 19, 2026 by jwilbert

QUESTION:
The physician group practice that is affiliated with our health system wants to develop a peer review process for outpatient practitioners. Does this make sense and, if so, what are some considerations in setting up such a process?

ANSWER FROM HORTYSPRINGER ATTORNEY CHARLIE CHULACK:

Even though an answer to this question involves an evaluation of the unique circumstances of the group practice, there has been a significant increase in interest in this topic. In our experience, the motivation for wanting an outpatient peer review process makes sense. The groups with which we have worked are interested in enhanced mechanisms and processes to better evaluate clinical care and address conduct concerns for ambulatory care practitioners, rather than solely relying on the human resources/employment process. They are also interested in taking advantage of any available peer review protections under state law that may only apply if there is a peer review structure in place.

An outpatient peer review process can be modeled on the process for your hospital’s medical staff. However, the structure is usually scaled down. For example, Clinical Specialty Review Committees, if being used for specialty reviews and expertise as a part of the Medical Staff peer review process, are generally not needed for outpatient peer review (but, as noted below, you want to reference your state’s peer review statute to confirm that any chosen structure maximizes protections under the law). Instead, you can rely on Clinical Specialty Reviewers or assign a member from the outpatient peer review committee who has the specialty expertise or knowledge to perform the case review.

As noted above, an additional consideration is your state’s peer review statute. If the statute contemplates peer review protections for outpatient peer review, you want to make sure that your process is set up to take advantage of those protections. By way of example, Colorado law discusses “professional review committees” of “authorized entities” (e.g., hospitals and physician groups). These professional review committees may share information with one another – for example, from hospital to group and group to hospital. The committees and their individual members are entitled to certain immunities from liability, and the records of professional review committees are confidential and privileged. However, for these protections to apply under Colorado law, the authorized entity and professional review committee must have statutorily required policies and procedures in place describing, among other things, hearing and appeal rights for practitioners. The professional review committee also has to register with the state. Thus, any peer review policy for an outpatient professional review committee will need to have these requirements addressed to be eligible for the protections in Colorado.

If you have a quick question about this, e-mail Charlie Chulack at cchulack@hortyspringer.com. Also, tune in to The Brave New World of Ambulatory Peer Review, a podcast from Horty, Springer & Mattern attorneys Ian Donaldson and Charlie Chulack will be available on Wednesday, February 25, 2026 for more on this topic.

June 22, 2017

Posted on June 22, 2017 by hortyspringer

QUESTION: I am a new physician CEO at a physician group affiliated with a hospital system. I get calls and e-mails from physicians directly when they have concerns about the communication/behavior/responsiveness of other physicians, before any medical staff involvement. There is an agreement to share information between medical staff committees and the employer group. How should I respond?

ANSWER: It would be a good idea to develop a policy for the group as to how issues are triaged and addressed. If the issues primarily involve conduct in the hospital setting, as opposed to employment, you could still choose to handle them initially within the group process (and consider subsequent reporting if the issue is not resolved) or you could report the concerns to the appropriate individual in the hospital. That may be the CMO, a medical staff officer, or Leadership Council as described in a Medical Staff Professionalism Policy.

While it may be suitable for you to handle some issues in an informal way by your personal immediate involvement, too much of that style of intervention may not be a good use of your time. Many issues are best directed through appropriate channels within either the group or the hospital/medical staff. (That doesn’t necessarily mean too much bureaucracy!) There may be more to a story than what is reported by one person; often, more fact-gathering is needed.

For issues that implicate medical staff performance, in some systems, a group’s CMO may be appointed to a hospital medical staff peer review committee or may be invited to the Leadership Council or similar group. A Leadership Council is commonly composed of the officers, hospital CMO and key support staff, and can convene regularly or when an issue involving the hospital practice or behavior of an employed physician is to be triaged.

December 3, 2015

Posted on December 3, 2015December 3, 2015 by hortyspringer

QUESTION: The new, final, Stark regulations permit a hospital to provide financial assistance to a physician or physician group to employ or contract with certain non-physician practitioners. What types of non-physician practitioners are covered under the new regulations?

ANSWER: Hospitals may provide financial assistance to help physicians or a physician group hire or contract with physician assistants, nurse practitioners, clinical nurse specialists, certified nurse-midwives, clinical social workers, or clinical psychologists. Financial assistance for other types of non-physician practitioners, such as nurse anesthetists, physical therapists, and dietitians, is not covered by the new exception.