Mandated Peer (5F) Reports
Applicable Massachusetts Laws
NOTICE
Re-written sections of the Massachusetts laws and regulations applicable
to mandated peer reports are provided below. This is not the official
version of the Massachusetts General Laws and Massachusetts Code
of Regulations.
M.G.L. c. 112 §5F
Any health care provider, as defined in section one of chapter
one hundred and eleven, shall report to the board any person who
there is reasonable basis to believe is in violation of section
five, or any of the regulations of the board, except as otherwise
prohibited by law.
No employer or duly authorized agent of an employer shall discharge,
refuse to hire or in any other manner discriminate against an employee
because the employee has made a report to the board as required
under this section, or has testified or in any manner cooperated
with an inquiry or proceeding pursuant to this chapter, unless the
employee knowingly participated in a fraudulent proceeding. Any
person claiming to be aggrieved by a violation of this section may
initiate proceedings in the superior court department of the trial
court for the county in which the alleged violation occurred. An
employer found to have violated this paragraph shall be exclusively
liable to pay to the employee lost wages, shall grant the employee
suitable employment, and shall reimburse such reasonable attorney
fees incurred in the protection of rights granted by this section.
The court may grant whatever equitable relief it deems necessary
to protect rights granted by this section. The board may, by regulation,
exempt a health care provider from the reporting obligation under
this section, as to a physician who is in compliance with the requirements
of a drug or alcohol program satisfactory to the board, or who has
successfully concluded such a program subsequent to the actions
or circumstances as to which reporting would otherwise be required.
M.G.L. c. 112 §5G(b)
(b) No person who reports information to the board as required
in section five A through section five F inclusive, or as required
in any other law or regulation shall be liable in any cause of action
arising out of such report provided that such person acts in good
faith and with a reasonable belief that such report was required.
If such an action is instituted against a person who reports to
the board as required in sections five A to five F, inclusive, and
such action is determined by the court to be insubstantial, frivolous
and not advanced in good faith, then such person defending such
action may be awarded reasonable counsel fees and other costs and
expenses incurred in defending against such action pursuant to section
six F of chapter two hundred and thirty-one.
M.G.L. c. 111 §1
(excerpt below includes definition of health care provider,
only)
The following words as used in this chapter, unless a different
meaning is required by the context or is specifically prescribed,
shall have the following meanings:
“Health care provider”, any doctor of medicine, osteopathy,
or dental science, or a registered nurse, social worker, doctor
of chiropractic, or psychologist licensed under the provisions of
chapter one hundred and twelve, or an intern, or a resident, fellow
or medical officer licensed under section nine of said chapter one
hundred and twelve, or a hospital, clinic or nursing home licensed
under the provisions of chapter one hundred and eleven and its agents
and employees.
M.G.L. c. 112 §5
(excerpt below includes grounds for disciplinary action,
only)
The board may, after a hearing pursuant to chapter thirty A, revoke,
suspend, or cancel the certificate of registration, or reprimand,
censure, impose a fine not to exceed ten thousand dollars for each
classification of violation, require the performance of up to one
hundred hours of public service, in a manner and at a time and place
to be determined by the board, require a course of education or
training or otherwise discipline a physician registered under said
sections upon proof satisfactory to a majority of the board that
said physician:-
- "fraudulently procured said certificate of registration;
- is guilty of an offense against any provision of the laws of
the commonwealth relating to the practice of medicine, or any rule
or regulation adopted thereunder;
- is guilty of conduct which places into question the physician’s
competence to practice medicine, including but not limited to gross
misconduct in the practice of medicine or of practicing medicine
fraudulently, or beyond its authorized scope, or with gross incompetence,
or with gross negligence on a particular occasion or negligence
on repeated occasions;
- is guilty of practicing medicine while the ability to practice
is impaired by alcohol, drugs, physical disability or mental instability;
- is guilty of being habitually drunk or being or having been
addicted to, dependent on, or a habitual user of narcotics, barbiturates,
amphetamines, hallucinogens, or other drugs having similar effects;
- is guilty of knowingly permitting, aiding or abetting an unlicensed
person to perform activities requiring a license for purposes of
fraud, deception or personal gain, excluding activities permissible
under any provision of the laws of the commonwealth relative to
the training of medical providers in authorized health care institutions
and facilities;
- has been convicted of a criminal offense which reasonably calls
into question his ability to practice medicine;
- is guilty of violating any rule or regulation of the board,
governing the practice of medicine.
The board shall, after proper notice and hearing, adopt rules and
regulations governing the practice of medicine in order to promote
the public health, welfare, and safety and nothing in this section
shall be construed to limit this general power of the board.
No person filing a complaint or reporting or providing information
pursuant to this section or assisting the board at its request in
any manner in discharging its duties and functions shall be liable
in any cause of action arising out of the receiving of such information
or assistance, provided the person making the complaint or reporting
or providing such information or assistance does so in good faith
and without malice. The board, including but not limited to the
data repository and the disciplinary unit, shall keep confidential
any complaint, report, record or other information received or kept
by the board in connection with an investigation conducted by the
board pursuant to this section, or otherwise obtained by or retained
in the data repository; provided, however, that, except to the extent
that the disclosures of records or other information may be restricted
as otherwise provided by law, or by the board’s regulations,
investigative records or information of the board shall not be kept
confidential after the board has disposed of the matter under investigation
by issuing an order to show cause, by dismissing a complaint or
by taking other final action nor shall the requirement that investigative
records or information be kept confidential at any time apply to
requests from the person under investigation, the complainant, or
other state or federal agencies, boards or institutions as the board
shall determine by regulations. Any employee of the board who is
found to be in violation of the confidentiality provisions of this
section or any other confidentiality law or regulation which is
applicable to the board shall be subject to a fine of not more than
five hundred dollars. Said fine shall be assessed and collected
by said board.
243 CMR 1.03(5)
Grounds for Complaint
- Specific Grounds for Compaints Against Physicians. A complaint
against a physician must allege that a licensee is practicing
medicine in violation of law, regulations, or good and accepted
medical practice and may be founded on any of the following:
- Fraudulent procurement of his/her certificate of registration
or its renewal;
- Commitment of an offense against any provision of the laws
of the Commonwealth relating to the practice of medicine, or
any rule or regulation adopted thereunder;
- Conduct which places into question the physician’s competence
to practice medicine, including but not limited to gross misconduct
in the practice of medicine, or practicing medicine fraudulently,
or beyond its authorized scope, or with gross incompetence,
or with gross negligence on a particular occasion or negligence
on repeated occasions;
- Practicing medicine while the ability to practice is impaired
by alcohol, drugs, physical disability or mental instability;
- Being habitually drunk or being or having been addicted to,
dependent on, or a habitual user of narcotics, barbiturates,
amphetamines, hallucinogens, or other drugs having similar effects;
- Knowingly permitting, aiding or abetting an unlicensed person
to perform activities requiring a license.
- Conviction of any crime;
- Continuing to practice while his/her registration is lapsed,
suspended, or revoked;
- Being insane;
- Practicing medicine deceitfully, or engaging in conduct which
has the capacity to deceive or defraud.
- Violation of any rule or regulation of the Board;
- Having been disciplined in another jurisdiction in any way
by the proper licensing authority for reasons substantially
the same as those set forth in M.G.L. c. 112 §5 or 243CMR
1.03(5);
- Violation of 243 CMR 2.07(15);
- Cheating on or attempting to compromise the integrity of any
medical licensing examination;
- Failure to report to the Board, within the time period provided
by law or regulation, any disciplinary action taken against
the licensee by another licensing jurisdiction (United States
or foreign), by any health care institution, by any professional
or medical society or association, by any governmental agency,
by any law enforcement agency, or by any court for acts or conduct
substantially the same as acts or conduct which would constitute
grounds for complaint as defined in this section;
- Failure to respond to a subpoena or to furnish the Board,
its investigators or representatives, documents, information
or testimony to which the Board is legally entitled;
- Malpractice within the meaning of M.G.L. c. 112 §61;
- Misconduct in the practice of medicine.
- Other Grounds for Complaints Against Physicians. Nothing herein
shall limit the Board’s adoption of policies and grounds
for discipline through adjudication as well as through rule-making.
243 CMR 2.07 (23)
Exception for reports to the Board under M.G.L. c. 112 §5F
A health care provider (“reporter”), as defined by
M.G.L. c. 111 §1, who is required to report a subject physician
to the Board pursuant to M.G.L. c. 112 §5F, is exempt from
filing such a report if all of the following conditions are present:
- The reporter has a reasonable basis to believe that the subject
physician is or has been impaired by, dependent upon or misusing
alcohol or drugs such that a report could be required under M.G.L.
c. 112 §5F, and is not otherwise in violation of M.G.L. c.
112 §5 or 243 CMR 1.00-3.00.
- The subject physician is currently in compliance with a drug
or alcohol program, or the reporter obtains direct confirmation
from such drug or alcohol program, within thirty days of acquiring
the “reasonable basis to believe” under 243 CMR 2.07
(23)(a), that the subject physician is in compliance with such program.
- The drug or alcohol program is approved by a majority vote of
the Board. Approval may be withdrawn, at any time, for cause, by
majority vote of the Board and with reasonable advance notice to
the program of the reasons for the proposed withdrawal of approval
and an opportunity to dispute such reasons. However, nothing herein
shall be construed to provide a right to an adjudicatory hearing
pursuant to M.G.L. c. 30A.
- The drug or alcohol program requires as a condition of the subject
physician’s participation that the subject physician consent,
pursuant to 42 CFR Part 2, to disclosure of relevant information
to the Board, under any of the following conditions:
- If the subject physician fails to correct, within a reasonable
period of time, a failure to provide documentation of his continuing
freedom from chemical dependence.
- If the subject physician is known by the program to be in a state
of chemical dependence, or if the subject physician is in a state
of chemical dependence, or if the subject physician is in a state
of chemical dependence after signing her contract with the program.
- If the program has a reasonable basis to believe that the subject
physician, for any reason, cannot render professional services without
undue risk to the public.
- If the subject physician revokes consent to disclose information
to the Board during the course of the subject physician’s
contract with the program.
- If the subject physician terminates her contract with the program
for any reason other than her successful recovery, in which the
program concurs.
- The drug or alcohol program requires that the subject physician
consent to confirmation to the reporter, pursuant to 42 CFR Part
2, that the subject physician is participating in the program, to
the extent that the reporter needs such confirmation pursuant to
243 CMR 2.07(23)(b).
- The subject physician’s involvement with alcohol or drugs
has not involved an allegation of patient harm.
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