On July 9, 2025, revisions to the New York regulations on recredentialing hospital Medical Staff members were finalized. In a post in the New York State Register, the Department of Health (DOH) finalized regulations permitting Medical Staff recredentialing decisions to be made at least triennially instead of biennially, as previously required. When originally proposed, this change appeared to be an attempt to make the New York requirement consistent with the accreditation standards of the Joint Commission (a nationally recognized hospital accreditation organization). While one internal discrepancy in the proposed regulatory revisions was corrected, DOH declined to revise other language to permit hospitals to also move to a triennial cycle for updating the information that must be maintained in Medical Staff recredentialing files – the current regulations require this information to be updated at least biennially.
Last summer, Hancock formally recommended to DOH that the scheduling flexibility proposed for recredentialing decision-making should likewise flow to the process of updating Medical Staff recredentialing files. Noting that it made sense for recredentialing decisions to occur at the same time that information in the files was updated, Hancock also noted that a failure to permit these timeframes to be consistent would complicate–not streamline–a hospital’s work processes and workload for the Medical Staff recredentialing process. DOH responded to Hancock’s recommendation as follows:
“Commenter’s proposed change to 10 NYCRR § 405.6(b)(7)(v) does not address the review of credentials timeline; rather it addresses the maintenance of a file timeline. Since these are different processes and different timelines, no change to 10 NYCRR § 405.6(b)(7)(v) is needed, and no changes to the regulation were made as a result of this comment.”
No further explanation was provided as to the goal of allowing information collection to be disconnected from decision-making timeframes and processes.
Hancock is pursuing further discussion with DOH on this issue, in hopes of finding a path to make the two timeframes consistent. In the interim, Hancock recommends that Medical Staff recredentialing decision making rely upon the most up-to-date information available. Thus, a hospital can either stick to a biennial recredentialing cycle or, if a hospital chooses to move to a triennial recredentialing schedule, it should update Medical Staff recredentialing files prior to making such triennial recredentialing decisions, even if that means undertaking additional data collection in the “off” years. In addition, Hancock cautions that if a hospital chooses to implement a triennial recredentialing schedule, any adverse information uncovered during the mandatory biennial Medical Staff recredentialing file updating should not, in the “off years”, be left until the next triennial recredentialing process. Rather, the hospital should take steps to assess and, if required, address the updated information in a timely fashion.
Hancock will post additional Alerts if more information becomes available.
