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Hospital Reporting Requirements FAQ

10-DAY HOSPITAL REPORTING REQUIREMENTS TO THE
MARYLAND BOARD OF PHYSICIANS

Introduction

The Maryland Board of Physicians (“Board”) is responsible for licensing and disciplining physicians, physician assistants, respiratory care practitioners, licensed radiation therapists, radiographers, nuclear medicine technologists, radiologist assistants, and polysomnographic technologists. By law, hospitals must report to the Board – within 10 days of action – any action taken that immediately affects the privileges of a practitioner or any other health professional regulated by the Board, based on any of the grounds listed in Sections 14-404 (Physicians), 14-5A-17 (Respiratory Care), 14-5B-14 (Radiation Therapists, Radiographers, Nuclear Medicine Technologists, and Radiologist Assistants), 15-314 (Physician Assistants), and 14-5C-17 (Polysomnographic Technologists) of the Medical Practice Act. These matters generally relate to questions of competence, performance, unprofessional practices and unethical practices.

This reporting requirement assures that the Board is aware of any problems involving the practice of medicine. However, the Board recognizes that there may be some confusion interpreting what is or is not a reportable action under the law.

These are the most frequently asked questions and answers regarding hospital reporting requirements. The Board hopes that these simple questions and answers will alleviate some of the confusion. When in doubt, the hospital is encouraged to report. The Board will, in turn, determine which reports warrant possible disciplinary action.

The Most Commonly Asked Questions Regarding Hospital Reporting Requirements under Maryland Annotated Code, Health Occupations Article, Sections 14-413 (Physicians), 14-5A-18 (Respiratory Care), 14-5B-15 (Radiation Therapists, Radiographers, Nuclear Medicine Technologists, and Radiologist Assistants), 14-5C-18 (Polysomnographic Technologists), and Code of Maryland Regulations 10.32.03.13 and 10.32.03.14 (Physician Assistants).

Questions:

1 Should a hospital report to the Board that a new applicant to the medical staff has been denied appointment?

2 If a new applicant withdraws his/her application before the Credentials Committee considers it, is this reportable?

3 If a practitioner is denied specific privileges on initial appointments because he/she lacks experience in a particular medical procedure, is that reportable?

4 If a practitioner’s privileges are reduced because he/she has not met a minimum level necessary to assure continued competence, (i.e., must perform five procedures per year to show competency, etc.) and this reduction is not due to any bad outcome, is this reportable?

5 Are “administrative” reductions (i.e., delinquent medical records) reportable actions?

6 If privileges are changed from active to consulting at a practitioner’s request, and this change is NOT related to competence, performance, unprofessional practices and unethical practices, is this reportable?

7 If a practitioner is “slowing down” and wishes to voluntarily limit his/her privileges, is this reportable?

8 If a new practitioner’s probationary period is extended past the usual one year, is this reportable?

9 When is an action reportable?

10 Are suspensions of less than 30 days reportable?

11 Is a requirement that a practitioner receive a mandatory consultation prior to performing a procedure considered a change of privileges and therefore reportable?

12 If a practitioner is appointed to the staff and it is learned during the provisional appointment period that he/she lacks the level of knowledge needed to treat the hospital’s patient population, is failure to grant him/her full appointment reportable?

13 Does the report to the Board satisfy the hospital’s obligation to report to the National Practitioner Data Bank?

14 Will the Board notify hospitals at which a practitioner has privileges when a Health Care Alternative Dispute Resolution Office claim has been filed against him/her?

15 How can the hospital obtain a copy of a claim?

16 Will the Board notify hospitals of the outcome of claims?

17 Will the Board notify hospitals at which a practitioner has privileges when the Board issues a Public Board Order or when another hospital takes action?

18 When in doubt, what should a hospital do?

19 Whom do hospitals contact?

20 Where should reports be sent?

1.	Question: Should a hospital report to the Board that a new applicant to the medical staff has been denied appointment? (back to top)
	Answer: Yes, a report should be made if the denial was based on a question of the applicant’s competence, performance, unprofessional practices and unethical practices or other actions which may be grounds for discipline under HO 14-404, 14-5A-17, 14-5B-14, and COMAR 10.32.03.06.

2.	Question: If a new applicant withdraws his/her application before the Credentials Committee considers it, is this reportable?(back to top)
	Answer: No, except if the Credentials Committee communicated to the applicant that the application would be denied unless it was withdrawn. For purposes of the reporting requirement, the Board considers this a denial which may be grounds for discipline under HO 14-404, 14-5A-17, 14-5B-14, and COMAR 10.32.03.06.

3.	Question: If a practitioner is denied specific privileges on initial appointments because he/she lacks experience in a particular medical procedure, is that reportable?(back to top)
	Answer: No.

4.	Question: If a practitioner’s privileges are reduced because he/she has not met a minimum level necessary to assure continued competence, (i.e., must perform five procedures per year to show competency, etc.) and this reduction is not due to any bad outcome, is this reportable?(back to top)
	Answer: No.

5.	Question: Are “administrative” reductions (i.e., delinquent medical records) reportable actions?(back to top)
	Answer: The hospital should report to the Board delinquent medical records if failure to complete medical records affects patient care and results in an adverse action.

6.	Question: If privileges are changed from active to consulting at a practitioner’s request, and this change is NOT related to competence, performance, unprofessional practices and unethical practices, is this reportable?(back to top)
	Answer: No.

7.	Question: If a practitioner is “slowing down” and wishes to voluntarily limit his/her privileges, is this reportable?(back to top)
	Answer: No, unless the “slowing down” is at the behest of the hospital because of competence, performance, unprofessional practices and unethical practices.

8.	Question: If a new practitioner’s probationary period is extended past the usual one year, is this reportable?(back to top)
	Answer: A report should be made only if the extension is based on problems with the practice of medicine, competence, performance, unprofessional practices and unethical practices.

9.	Question: When is an action reportable?(back to top)
	Answer: As soon as any change takes place with the individual’s privileges, NOT after the appeal process.

10.	Question: Are suspensions of less than 30 days reportable?(back to top)
	Answer: Yes.

11.	Question: Is a requirement that a practitioner receive a mandatory consultation prior to performing a procedure considered a change of privileges and therefore reportable?(back to top)
	Answer: Yes, if the practitioner was not previously required to obtain prior consultation and the reason for the change is competence, performance, unprofessional practices and unethical practices.

12.	Question: If a practitioner is appointed to the staff and it is learned during the provisional appointment period that he/she lacks the level of knowledge needed to treat the hospital’s patient population, is failure to grant him/her full appointment reportable?(back to top)
	Answer: Yes.

13.	Question: Does the report to the Board satisfy the hospital’s obligation to report to the National Practitioner Data Bank? (back to top)
	Answer: No. Reports to the National Practitioner Data Bank are governed by federal law (U.S. P.L. 99-6600) and regulations (45 CFR Part 60), and the “Adverse Action Report”.

14.	Question: Will the Board notify hospitals at which a practitioner has privileges when a Health Care Alternative Dispute Resolution Office claim has been filed against him/her?(back to top)
	Answer: Yes.

15.	Question: How can the hospital obtain a copy of a claim?(back to top)
	Answer: Copies of claims may be obtained from the Health Care Alternative Dispute Resolution Office.

16.	Question: Will the Board notify hospitals of the outcome of claims?(back to top)
	Answer: No.

17.	Question: Will the Board notify hospitals at which a practitioner has privileges when the Board issues a Public Board Order or when another hospital takes action.(back to top)
	Answer: Yes. In addition, this information is available on the Board Facility web page.

18.	Question: When in doubt, what should a hospital do?(back to top)
	Answer: Contact the Board and explain the situation.

19.	Question: Whom do hospitals contact?(back to top)
	Answer: Kim Jackson (410-764-4780) or Yemisi Koya, Outreach & Communications, (410-764-4798), 4201 Patterson Avenue, Baltimore, MD 21215.

20.	Question: Where should reports be sent?(back to top)
	Answer: Compliance Division, Maryland Board of Physicians, 4201 Patterson Avenue, Baltimore, MD 21215.

September 2010

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