Process for Handling Complaints Related to Continuing Medical Education by MMS-Accredited Providers

Note: This process applies only to complaints regarding providers of Continuing Medical Education; it does not cover providers of health care.

A. Complaint Status and Statute of Limitation

  1. Complaints are written notifications to the Massachusetts Medical Society (MMS) by a third party which claim that an MMS accredited Provider ("Provider") is not in compliance with MMS Rules (defined herein as MMS Policies, ACCME Standards for Commercial SupportSM, Essential Areas and Elements and accreditation criteria required by the MMS) with regard to one or more of its activities ("Complaint").

  2. To receive status as a Complaint, the written Complaint must identify the accredited Provider, identify the CME activity in question if applicable, and confirm the name, US Postal Service address and contact information of the person making the submission ("Complainant").  The MMS will send a letter of acknowledgement to the Complainant confirming that the Complaint has been received and will be reviewed. 

  3. A Complaint may refer to a) single activities/series, or b) the Provider's entire program of continuing medical education (CME).

  4. The statute of limitation of the length of time during which an accredited Provider must be accountable for any Complaint by the MMS is twelve (12) months from the date a live activity is ended, or in the case of a series, twelve (12) months from the date of the session which is in question.  Providers are accountable for an Enduring Material during the period of time it is being offered for AMA PRA Category 1 Credit™ CME, and twelve (12) months thereafter.

  5. MMS may initiate a Complaint against an accredited Provider.

B. Procedure for Complaint Review  and Provider Response

  1. MMS will review the Complaint to determine whether it relates to the manner in which the Provider complies with the MMS's Rules.

  2. If the Complaint does not relate to the Provider's compliance with MMS Rules, the Complainant will be advised of MMS's position and the Complaint process will be closed.

  3. If the MMS determines that the Complaint relates to the Provider's compliance with MMS Rules, then MMS will send a letter which identifies the alleged non-compliance to the Provider ("Notice of Complaint").  The Notice of Complaint from MMS may include a request for documents or data from the Provider.  MMS will attach a redacted copy of the Complaint to the Notice of Complaint.  The identity of the Complainant will be deleted from the Complaint.  To the extent feasible, MMS will not disclose the identity of the Complainant during the Complaint process, but the identity of a Complainant may be evident due to the circumstances of the Complaint, and the Complainant's identity may be revealed in a legal proceeding.

  4. The Provider shall either admit the allegations of the Complaint or provide a written rebuttal and any information requested by the MMS within forty-five (45) days of receipt of the Notice of Complaint.  The Provider's failure to provide information requested by the MMS within the forty-five (45) day time limit may contribute to a finding of non-compliance.  The Provider will be informed in writing that a change of status to Non Accreditation may occur if the Provider has failed to respond to the request for information in the manner stipulated by the MMS.

C. MMS Findings and Decisions

  1. Subject to the Complaint, the Provider will be found in Compliance or Not in Compliance for that activity.  The completed process and the findings will be kept confidential by MMS, with the exception of MMS's response to a lawful subpoena or other legal process; provided, however, that MMS reserves the right to make public the non-compliance issue without naming the Provider which was in non-compliance.

  2. The Provider will be notified of the finding. If the finding is Not in Compliance, the non-compliance will be described in a Notice of Non-Compliance to the Provider.
    1. If an activity is found to be in Non-Compliance with the ACCME Standards for Commercial  Support 1 (Independence), Standard for Commercial Support 5 (Content and Format without Commercial Bias), or the Content Validation Value Statements, the accredited provider is required to provide corrective information to the learners, faculty, and planners.  The provider will submit to the MMS a report describing the action that was taken and the information that was transmitted.  Providers will determine how to communicate the corrective information and are under no obligation to communicate that the activity was found in Non-compliance with MMS requirements.

    2. In addition, the MMS may also take the following actions in response to a  finding  of non-compliance:
      1. MMS may require the Provider to submit documentation of corrective action within thirty (30) days of receipt of the Notice of Non-Compliance.

      2. MMS may require the Provider to submit a Monitoring Progress Report at a time determined by the MMS.

      3. MMS may change the Provider's accreditation status to Probation or Non-Accreditation;  and

      4. If the Provider fails to convert Non-Compliance to Compliance via documentation of corrective action, monitoring progress report, or other remedial measures, MMS reserves the right to change the Provider's accreditation status to Probation or Non-Accreditation.

    3. If a Provider is found Not in Compliance, documents related to the Complaint review (such as the Complaint, Notice of Complaint, Provider's response, documentation of corrective action, or monitoring progress report) will be placed in the Provider's file and made available to the survey team and MMS Committee on Accreditation Review as part of the MMS reaccreditation process.

  3. After a decision has been made, the Complainant will receive a Letter of Acknowledgement indicating the Complaint has been reviewed, appropriate steps taken as necessary, and the matter is closed. 

  4. At any point in the Complaint process, the MMS reserves the right to require an immediate full or focused accreditation survey, including a full or focused self-study report and interview.

  5. When asked for "documentation of corrective action", the Provider will be asked to provide documentation of corrective action to the MMS within thirty (30) days of receipt of the Notice of Non-Compliance, and will be notified that failure to correct the deficiencies may result in an immediate resurvey which may affect the Provider's accreditation status.

  6. If the Monitoring Progress Report adequately describes and documents Compliance, it will be accepted.  If the Monitoring Progress Report does not adequately describe and/or document Compliance, it will NOT be accepted.

  7. Regarding Request for Information or Response:  Change of status to Probation may automatically occur at forty-five (45) days from the time the Provider receives a request for information/response from the MMS, if the Provider has failed to provide a response or provide the requested information.

  8. Regarding Documentation of Corrective Action:  Change of status to Probation may automatically occur at fifteen (15) days after the due date for the notice set by the MMS, if the Provider has failed to submit the required documentation of corrective action.

  9. Regarding Monitoring Progress Report:  Change of status to Probation may automatically occur at thirty (30) days after the due date for the Monitoring Progress Report set by the MMS, if the Provider has failed to submit the required Monitoring Progress Report.

    Each instance of a failure by a Provider to respond as described in paragraphs 7-9 shall be considered a "failure to submit."

  10. Change of status to Non-Accreditation may occur at thirty (30) days from the date a Provider was placed on Probation for failure to submit information or a response, documentation of corrective action, or a Monitoring Progress Report if the Provider has still failed to submit the required information and/or documentation.  Change of status to Probation or Non-Accreditation for "failure to submit" does not require MMS Committee on Accreditation Review action.

  11. MMS will send a notice to the Provider of a change of status in a manner that confirms receipt (e.g., email, USPS certified mail, FEDEX-type courier).

  12. Except for an automatic change in status due to a Provider's "failure to submit", a Provider's compliance must be reviewed by the MMS's Committee on Accreditation Review to either a) change the Provider's accreditation status to Probation or Non-Accreditation or b) proceed with a full or focused accreditation survey, including a full or focused self-study report and interview.

Complaints may be submitted to:

Nancy Marotta
Manager, Recognized Accreditor Program
Massachusetts Medical Society
860 Winter Street
Waltham, MA 02451
(781) 434-7906
(781) 642-1246 (Fax)
nmarotta@mms.org

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