Medical Staff Operations and Disputes


Hooper, Lundy & Bookman provides comprehensive counsel to support medical staff officers and Executive Committees, health care executives, medical staff administrators, and other professional staff leaders in managing medical staff operations and addressing concerns associated with peer review and reporting obligations. HLB attorneys focus on maximizing quality of care while ensuring fair procedures and due process.

With attorneys who understand both the legal and operational issues involved in the relationships among providers, medical staffs, hospitals, health plans, foundations, and medical groups, HLB has earned the trust of medical staff and hospital leaders for providing proactive and responsive guidance on day-to-day and long-term issues. HLB attorneys represent medical staffs of all sizes, including government-run facilities, private and public hospitals, community-based medical centers, large health systems, and academic medical centers. 

HLB has been at the forefront of medical staff issues since the firm’s founding. HLB’s attorneys have been involved in some of the most impactful medical staff cases of the past several decades, shaping the legal landscape that governs relationships within the industry. HLB’s Medical Staff Practice Group is a leader in the industry, providing guidance on myriad medical staff issues, including internal governance, credentialing, and investigations through fair hearings and litigation. When medical staff issues arise, our attorneys move swiftly and strategically to find resolutions that diffuse the matter at hand while avoiding outcomes that could set counterproductive precedents. 

HLB attorneys represent medical staffs in peer review hearings and governing bodies in appeals arising out of fair hearing proceedings. HLB attorneys handle writs of mandate and federal and state civil litigation relating to medical staff affairs in all forums and assist our clients with responding to subpoenas from state medical boards and other professional licensing boards. Our medical staff operations and dispute capabilities extend not only to hospitals but to other entities with professional staff components or characteristics, including clinics, surgery centers, IPAs, health plans, and medical groups. We also provide hearing officer services in peer review hearings. 

Our wide-ranging and comprehensive counsel on medical staff matters includes:


  • Medical Staff Bylaws
  • Rules & Regulations
  • Credentialing and privileging policies
  • Delineation of Privileges protocols and requirements
  • Fair hearing policies
  • Late career practitioner policies
  • Behavior policies and Codes of Conduct
  • Practitioner Well-Being and Wellness policies
  • Focused Professional Practice Evaluation and Ongoing Professional Practice Evaluation (FPPE/OPPE) policies
  • Advanced Practice Provider and Allied Health Professional policies
  • Leave of absence policies
  • End-of-life policies
  • Information sharing agreements
  • Return to Practice Plans

Consultative Services

  • Medical staff self-governance and operations
  • Hospital/medical staff relations
  • Medical staff in multi-hospital systems
  • Formation of new or consolidated medical staffs
  • Medical staff credentialing
  • Medical staff investigations and remedial action proceedings involving behavioral and clinical issues
  • Joint investigations
  • Preservation of peer review confidentiality protections and immunities
  • Hospital licensing, Medicare Conditions of Participation, and accreditation compliance
  • State Professional Licensing Board and National Practitioner Data Bank reporting and dispute resolution
  • Responses to Medical Board and State Professional Licensing Board subpoenas
  • Medical administrative officer contracts
  • Behavior agreements
  • Department/service closures
  • Exclusive contracting
  • Patient safety whistleblower complaints
  • Practitioner scope of practice issues
  • Effective use of Well-Being Committees and protection of physician medical information
  • Health equity
  • Reproductive health
  • Telehealth credentialing issues

Advocacy Representation

  • Peer review hearings, governing board appeals, and writs 
  • Hearing officer services in peer review hearings
  • Representation of hospitals and medical staff in litigation relating to medical staff affairs, including Health & Safety Code Section 1278.5 litigation in all forums
  • Evidence Code Section 1157, HCQIA, and other confidentiality protections

Key Contacts

Jennifer A. Hansen
San Diego