Peer Reports Laws & Regulations

Laws and regulations regarding mandated reporting by providers

Sections describing 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.

Laws and regulations

M.G.L. c. 112 §5F

Any health care provider, as defined in section one of chapter one hundred and eleven – Consumer Guide to the Complaint Process, 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, or a public hospital 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:-

  1. "fraudulently procured said certificate of registration;
  2. 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;
  3. 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;
  4. is guilty of practicing medicine while the ability to practice is impaired by alcohol, drugs, physical disability or mental instability;
  5. 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;
  6. 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;
  7. has been convicted of a criminal offense which reasonably calls into question his ability to practice medicine;
  8. 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

  1. Specific Grounds for Complaints 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:
    1. Fraudulent procurement of his/her certificate of registration or its renewal;
    2. 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;
    3. 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;
    4. Practicing medicine while the ability to practice is impaired by alcohol, drugs, physical disability or mental instability;
    5. 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;
    6. Knowingly permitting, aiding or abetting an unlicensed person to perform activities requiring a license.
    7. Conviction of any crime;
    8. Continuing to practice while his/her registration is lapsed, suspended, or revoked;
    9. Being insane;
    10. Practicing medicine deceitfully, or engaging in conduct which has the capacity to deceive or defraud.
    11. Violation of any rule or regulation of the Board;
    12. 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);
    13. Violation of 243 CMR 2.07(15): Medicare Payments:
    14. Cheating on or attempting to compromise the integrity of any medical licensing examination;
    15. 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 243 CMR 1.03(5);
    16. 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;
    17. Malpractice within the meaning of M.G.L. c. 112 §61;
    18. Misconduct in the practice of medicine.
  2. Other Grounds for Complaints Against Physicians. Nothing in 243 CMR 1.00 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:

  1. Requirements for Reporting Exception to Apply. A health care provider (reporter), as defined by M.G.L. c. 111, § 1, who is required to report a physician to the Board pursuant to M.G.L. c. 112, § 5F, is exempt from filing such a report if all three of the following conditions are present:

1.Reasonable Basis to Believe Impairment. The reporter has a reasonable basis to believe that the 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 that the physician has not violated any other Board statute or regulation as set forth in M.G.L. c. 112, § 5 or 243 CMR 1.00 through 3.00; and

2. No Allegation of Patient Harm. The physician's involvement with alcohol or drugs has not involved an allegation of patient harm; and

3. Confirmation of Compliance with the Treatment Program. The physician is currently in compliance with a drug or alcohol program, and the reporter obtains direct confirmation from such drug or alcohol program, within 30 days of acquiring the Reasonable Basis to Believe under 243 CMR 2.07(23)(a), that the physician is in compliance with such program. If the reporter fails to obtain direct confirmation from such program or if the physician at any time fails to comply with such program, the exception to the reporting requirement set forth in 243 CMR 2.07(23) ceases and the health care provider must report the impairment as required by M.G.L. c. 112, § 5F.

  1. Requirements for drug or alcohol program to qualify for 243 CMR 2.07(23).

1. The drug or alcohol program must be 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. 

2. The drug or alcohol program requires as a condition of the physician's participation that the physician consent, pursuant to 42 CFR 1, subpart A, part 2, subsection C, to disclosure of relevant information to the Board, under any of the following conditions: 

a. If the physician fails to correct, within a reasonable period of time, a failure to provide documentation of his or her continuing freedom from unauthorized substance use;

b. If the physician is known by the program to be in a state of unauthorized substance use, or if the physician is in a state of unauthorized substance use after signing his or her contract with the program;

c. If the program has a reasonable basis to believe that the physician, for any reason, cannot render professional services without undue risk to the public; d. If the physician revokes consent to disclose information to the Board during the course of his or her contract with the program; or e. If the physician terminates his or her contract with the program for any reason other than his or her successful recovery, in which the program concurs.

  1. The drug or alcohol program requires that the physician consent to confirmation to the reporter, pursuant to federal regulations, that the physician is participating in the program, to the extent that the reporter needs such confirmation pursuant to 243 CMR 2.07(23)(c).

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