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Adverse Peer Reviews, Complaints & The Texas Medical Board

Adverse Peer Reviews, Complaints & The Texas Medical Board
Hendershot, Cannon & Hisey, P.C.

Physicians are bound by a maze of regulatory, ethical, and professional duties, and there’s considerable potential for running afoul of any given law. Naturally, hospitals, medical practices, and the government encourage independent reviews and complaints to keep misconduct and substandard care in check.

Sometimes, that means providers face state or federal investigation over purported health care fraud, or an accidental violation of self-referral statutes. In other cases, physicians may confront professional licensing proceedings that put administrative penalties on the table, and create potential for further investigation and civil or criminal liability.

In any disciplinary action concerning a medical professional in Texas, risks for unfavorable outcomes cannot be understated – especially when they concern peer review hearings and filed complaints that make their way to the Texas Medical Board.

Just as there are risks for raw deals, however, there are also opportunities to proactively prepare, defend, and strategize ways to protect yourself and your career.

How Adverse Peer Review Proceedings Relate to TMB

The Texas Medical Board (TMB), through power granted by the Texas Medical Practice Act, has the authority to regulate practitioners and impose discipline upon the licenses it issues to physicians.

TMB licensing and credentialing matters may arise for a number of reasons, and investigations in particular often result from adverse peer reviews and submitted complaints. Here’s a brief breakdown of the interplay between these two administrative matters and where the Texas Medical Board fits in.

Medical Peer Reviews

The Texas Medical Board has a duty to keep patients safe, and does so through licensing and regulating physicians statewide. In order to best protect patients and initiate needed investigations in a timely manner, the TMB relies on hospitals and other health care entities to report medical peer review actions.

There are a few important laws and procedures related to medical peer reviews and the Texas Medical Board:

  • Entities Subject to Peer Review Laws – Peer review laws and reporting requirements apply broadly to “medical committees” and joint committees within hospitals, health care organizations, medical schools / health science centers, health maintenance entities, extended care centers, hospital districts, and hospital authorities, among other related medical entities.  Health care entity governing bodies have a right to review services and physicians (with some exceptions), and must maintain proper records and documentation.
  • Mandatory Reporting – The TX Occupations Code / Medical Practice Act (Ch. 160) mandates reporting to the TMB for specific instances, including: suspected drug or alcohol impairment, peer reviews resulting in adverse decisions / restricted clinical privileges over 30 days, physician surrender of privileges, adverse effects on a physician’s membership in a professional association, and any instance where physicians are believe to pose threats to public welfare.
  • Liability – Texas law places reporting obligations upon peer review committees, individual members, and health care entity leadership. Failures to report can result in investigations against all individuals and committees which hold these duties, and potential penalties.
  • Medical Peer Review Process – Both state and federal law encourage a fair and productive clinical peer review process by limiting immunity, and providing both peer committee members and physicians with certain privileges. Proceedings should be unbiased and, though they may vary from entity to entity, should generally consist of an investigation and a hearing (if requested). Physicians facing peer reviews, like any professional subject to administrative proceedings with potential for serious penalties and practice disputation, should would with experienced attorneys to ensure due process and carefully navigate the unique investigatory, notice, hearing, and rebuttal / defense of their entity’s peer review process.

Medical peer reviews concerning physician privileges and employment / medical contracts may directly result in further investigations conducted by the TMB or other regulatory authorities, or may result from audits and investigations already in progress or resolved.

Complaints

Most complaints related to physicians are directed to and handled by the Texas Medical Board, though some may begin with internal peer reviews or other agencies (i.e. OIG, DEA, FBI, etc.). Typically, these complaints are filed by patients, colleagues, personal friends or family members, or other physicians who subsequently treat the same patient.

Complaints, even when submitted anonymously, may also involve a number of red flags and substantive matters, including alleged or perceived:

  • Criminal conduct (arrests, convictions, etc.)
  • Behavior / crimes of moral turpitude (DWI, domestic violence, substance abuse, etc.)
  • Failures to meet accepted medical standards / duty of care
  • Record-keeping and documentation violations
  • Prescription violations / non-therapeutic prescribing practices
  • Physical or mental conditions / disabilities which interfere with practice of medicine
  • Probation / restricted privilege violations
  • Outcomes / findings of internal peer reviews, professional associations, or out-of-state licensing authorities

TMB Proceedings: Potential for Major Penalties

TMB disciplinary proceedings arising from complaints or adverse peer reviews can have varying timelines and repercussions, and create the need to tailored response strategies. Although cases vary, immediate and preventative action is critical to mitigating protracted, contested, and high-stakes proceedings – and potentially devastating penalties.

A TMB case may develop as follows:

  • Complaint submitted / received (Initial Complaint Letter)
  • Investigation by Texas Medical Board
  • Informal Settlement Conference (ISC)
  • Negotiations for Agreed Order
  • State Office of Administrative Hearings (SOAH)
  • SOAH Mediation or Appeals / Re-Consideration
  • Temporary Suspension / Imposition of Penalties
  • Hearings for Violations of Probation / Agreed Orders

Hendershot, Cannon & Hisey: Representation for Physicians & Health Care Providers

The health and medical law team at Hendershot, Cannon & Hisey, P.C. counsels and represents health care providers and businesses across Texas in preventative and responsive matters involving alleged health care fraud, hospital peer reviews, formal complaints, licensure defense, and disciplinary proceedings conducted by the Texas Medical Board and other similar health care licensing boards.

The regulatory landscape surrounding Texas Medical Board (TMB) proceedings and related health care investigations has intensified in recent years, and are contentious and concerning for the naïve, unprepared, or unrepresented physician. No matter the basis for these actions, they demand the attention of proven lawyers.

With extensive experience in health care matters involving state and federal regulatory / licensing authorities, our attorneys guide clients through high-stakes proceedings that put privileges, personal reputations, and professional careers on the line. To speak with a lawyer, call (713) 909-7323 or contact us online
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