42 U.S.C. § 11112 — Standards for professional review actions
submitted 40 years ago by Pub. L. 99-660 to r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE · 747 words · no verdicts yet
A qualifying professional-review action must be based on a reasonable belief that it advances quality care, a reasonable fact-finding effort, fair notice and hearing procedures, and a reasonable belief that the known facts justify it. The section describes procedures that count as adequate and permits immediate action in investigations or emergencies.
(a) For the protection in section 11111(a), a professional review action* must be taken:
(1) with a reasonable belief that it advances quality health care;
(2) after a reasonable effort to learn the facts;
(3) after giving the physician* adequate notice and hearing procedures, or other procedures that are fair in the circumstances; and
(4) with a reasonable belief that the known facts, after that effort and those procedures, justify the action. The action is presumed to meet these standards unless a preponderance of the evidence rebuts the presumption.
(b) A health care entity* is treated as meeting the adequate-notice-and-hearing requirement if these conditions are met or the physician voluntarily waives them.
(b)(1) Proposed-action notice must state* that a professional review action is proposed and why; that the physician may request a hearing; the deadline, which must be at least 30 days; and a summary of the hearing rights in paragraph (3).
(b)(2) If the physician timely requests a hearing, notice must state its place, time, and date, with the date at least 30 days after the notice, and list expected witnesses for the review body.
(b)(3)(A) The hearing must be before an arbitrator acceptable to both sides, a hearing officer appointed by the entity who is not in direct economic competition with the physician, or a panel appointed by the entity whose members are not in such competition.
(b)(3)(B) The physician may lose the hearing right by failing to appear without good cause.
(b)(3)(C) At the hearing, the physician may choose an attorney or other representative; have a record made and obtain copies on paying reasonable preparation charges; call, examine, and cross-examine witnesses; present evidence the hearing officer considers relevant even if a court would not admit it; and submit a written statement at the end.
(b)(3)(D) After the hearing, the physician has the right to receive the arbitrator’s, officer’s, or panel’s written recommendation, including the basis for the recommendation, and the health care entity’s written decision, including the basis for the decision. A body’s failure to meet these listed conditions alone does not establish that it failed subsection (a)(3).
(c) Nothing here requires the subsection (a)(3) procedures when no adverse professional review action is taken, or for a clinical-privilege suspension or restriction lasting no more than 14 days while an investigation determines whether action is needed. Nothing here prevents an immediate suspension or restriction, followed by notice and a hearing or other adequate procedures, when failing to act could endanger someone’s health imminently.
For purposes of the protection set forth in section 11111(a) of this title, a professional review action* must be taken—
in the reasonable belief that the action was in the furtherance of quality health care,
after a reasonable effort to obtain the facts of the matter,
after adequate notice and hearing procedures are afforded to the physician* involved or after such other procedures as are fair to the physician under the circumstances, and
in the reasonable belief that the action was warranted by the facts known after such reasonable effort to obtain facts and after meeting the requirement of paragraph (3).
A professional review action shall be presumed to have met the preceding standards necessary for the protection set out in section 11111(a) of this title unless the presumption is rebutted by a preponderance of the evidence.
A health care entity* is deemed to have met the adequate notice and hearing requirement of subsection (a)(3) with respect to a physician if the following conditions are met (or are waived voluntarily by the physician):
The physician has been given notice stating—
that a professional review action has been proposed to be taken against the physician,
reasons for the proposed action,
that the physician has the right to request a hearing on the proposed action,
any time limit (of not less than 30 days) within which to request such a hearing, and
a summary of the rights in the hearing under paragraph (3).
If a hearing is requested on a timely basis under paragraph (1)(B), the physician involved must be given notice stating—
the place, time, and date, of the hearing, which date shall not be less than 30 days after the date of the notice, and
a list of the witnesses (if any) expected to testify at the hearing on behalf of the professional review body*.
If a hearing is requested on a timely basis under paragraph (1)(B)—
subject to subparagraph (B), the hearing shall be held (as determined by the health care entity)—
before an arbitrator mutually acceptable to the physician and the health care entity,
before a hearing officer who is appointed by the entity and who is not in direct economic competition with the physician involved, or
before a panel of individuals who are appointed by the entity and are not in direct economic competition with the physician involved;
the right to the hearing may be forfeited if the physician fails, without good cause, to appear;
in the hearing the physician involved has the right—
to representation by an attorney or other person of the physician’s choice,
to have a record made of the proceedings, copies of which may be obtained by the physician upon payment of any reasonable charges associated with the preparation thereof,
to call, examine, and cross-examine witnesses,
to present evidence determined to be relevant by the hearing officer, regardless of its admissibility in a court of law, and
to submit a written statement at the close of the hearing; and
upon completion of the hearing, the physician involved has the right—
to receive the written recommendation of the arbitrator, officer, or panel, including a statement of the basis for the recommendations, and
to receive a written decision of the health care entity, including a statement of the basis for the decision.
A professional review body’s failure to meet the conditions described in this subsection shall not, in itself, constitute failure to meet the standards of subsection (a)(3).
For purposes of section 11111(a) of this title, nothing in this section shall be construed as—
requiring the procedures referred to in subsection (a)(3)—
where there is no adverse professional review action taken, or
in the case of a suspension or restriction of clinical privileges*, for a period of not longer than 14 days, during which an investigation is being conducted to determine the need for a professional review action; or
precluding an immediate suspension or restriction of clinical privileges, subject to subsequent notice and hearing or other adequate procedures, where the failure to take such an action may result in an imminent danger to the health of any individual.
Source credit: (Pub. L. 99–660, title IV, § 412, Nov. 14, 1986, 100 Stat. 3785.)
- 1986Enacted · Pub. L. 99-660 · 100 Stat. 3785
A history note hasn’t been published yet. The record shows enactment by Pub. L. 99-660 on 1986-11-14.
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