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How to report disciplinary actions taken against physicians


National Practitioner Data Bank (NPDB)

Board of Registration in Medicine

Who must report

  • Hospitals
  • Ambulatory Surgery Centers
  • Clinics
  • Nursing homes, rest homes, convalescent homes, and any other facility licensed under M.G.L. c. 111, §71

What to report

Either of the following:

1. A “professional review action” taken by your facility against a physician* that:

a. Adversely affects his/her clinical privileges for a period over 30 days; and

b. Relates to his/her competence or professional conduct, in a manner that has adversely affected (or could adversely affect) a patient’s health or welfare;

OR

2. The physician accepted the surrender or restrictions of clinical privileges while under your investigation or in lieu of an investigation or proceeding.

* Includes actions against dentists.

Any of the following disciplinary actions, or their substantial equivalent, taken by your facility against a physician:

Category 1: Reportable whether or not it relates to the physician's competence to practice medicine or a violation of law:

  • Revocation or suspension of a right or privilege;
  • Censure or written reprimand or admonition;
  • Fine;
  • Required performance of public service;
  • A course of education, training, counseling, or monitoring if the course arose out of the filing of a complaint or of any other formal charges that reflects upon the physician’s competence to practice medicine.

Category 2: Reportable only if it relates to the physician's competence to practice medicine or to a violation of law, regulation or by-law:

  • Restriction, non-renewal, or denial of a right or privilege;
  • Resignation or leave of absence;
  • Withdrawal of an application;
  • Termination or non-renewal of a contract with the licensee.

Exception: Disciplinary actions based on a physician’s failure to complete medical records in a timely fashion or to perform minor administrative functions are not reportable, unless it also relates to his/her competence to practice medicine or to a violation of law or Board regulation.

How to report

1. Report through the NPDB website

and

2. Provide a copy of the report to the Board of Registration in Medicine.

1. Mail or fax an initial report (Form HCFD-1) to the Board’s Data Repository Unit within 30 days of imposing the disciplinary action. If the disciplinary action is reversed, notify the DRU and file a subsequent report on Form HCFD-2 within 30 days of the reversal.

2. If the disciplinary action is ongoing, submit a subsequent report (Form HCFD-2) :

  • At the end of every 60-day period of the ongoing action (as applicable), and
  • Within 30 days of the date of final action

3. By January 31, file an annual summary (Form HCFD-3) on disciplinary actions taken in the previous calendar year. Even if your facility made no disciplinary action reports that year, you must submit an annual summary.

All three forms are available on the Board’s website.

Resources

Reporting to the NPDB

Data Bank Guide For Reporting Clinical

Privileges Actions

NPDB: FAQs

Health Care Facility Disciplinary Action Reports

Definition of Disciplinary Action

Laws

45 CFR § 60.12

45 CFR § 60.3

MGL c. 111, §§ 53B, 203

243 CMR § 2.14(5)

243 CMR § 1.01(2)

Contact

The NPDB

P.O. Box 10832
Chantilly, VA 20153-0832

help@npdb.hrsa.gov

Phone: 1-800-767-6732
Fax: 1-703-803-1964

Contact NPDB
Data Repository Unit

Board of Registration in Medicine

200 Harvard Mill Square, Suite 330

Wakefield, MA 01880

Phone: 781-876-8200.

Fax: 781-876-8380