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California Attorney General Clarifies State Reporting Deadlines for Medical Staff Discipline

On April 17, 2020, the California Attorney General released Opinion No. 15-301, clarifying the deadlines for peer review bodies to file reports to certain licensing agencies pursuant to Business and Professions Code section 805 (805 Reports).

The Opinion explains that certain types of 805 Reports are due after a licentiate exercises or waives internal peer review hearing and appellate rights, not before.

The Question and the Opinion’s Answer

The Opinion addresses the following question from the Medical Board of California:

What is the meaning of the term “effective date,” as used in Business and Professions Code section 805, which requires a report to be filed with the relevant state healing arts licensing agency “within 15 days after the effective date” of certain actions taken by a peer review body against specified health care practice licentiates?

The Attorney General concluded that “‘effective date’ for these purposes means the date on which the triggering decision becomes final, which will generally be following the conclusion of the licentiate’s appeal of the peer review body’s decision.

Recommended Actions

Under this guidance, the 15-day reporting clock rarely starts immediately after the medical staff recommends disciplinary action. Instead, the 15-day clock almost always begins after the licentiate exercises or waives any hearing and appellate rights and the recommendation becomes the final action of the hospital governing body. Given the increasing length of many peer review hearings and appeals, the time difference between when the medical staff recommends discipline, and when the discipline becomes final and reportable, may be months, or even years.

Summary Actions: Suspensions and Restrictions

Although the Opinion does not directly address the timing for reporting summary actions, it does acknowledge in a footnote that peer review bodies can immediately suspend or restrict a licentiate under certain circumstances before providing a hearing. Regarding suspensions, Section 805(e) explicitly provides that 805 Reports must be filed “within 15 days following the imposition of summary suspension of staff privileges, membership, or employment, if the summary suspension remains in effect for a period in excess of 14 days.” Reporting therefore will necessarily occur before a hearing. Summary restrictions, on the other hand, become reportable after they are effective for 30 cumulative days in a 12-month period. Although Section 805 does not directly address reporting deadlines for summary restrictions, peer review bodies should report such a restriction within 15 days after the 30th day passes, regardless of whether or not the practitioner requests a hearing.

Section 805.01 Reports

Another type of report that is still due immediately is the often-overlooked report required by Business and Professions Code Section 805.01. That section applies when a medical staff recommends corrective action based on certain types of serious incompetence or misconduct.  The Section 805.01 report is due 15 days after the peer review body recommends action, whether or not any hearing has been requested or ever takes place.

Peer review bodies and health facilities should contact legal counsel to determine the correct filing deadline for 805 Reports under this new guidance. 

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