HCQIA Inmunity Lessons learned:An Analysis of Recent Cases Where Hospitals and Individuals Lost Their Bid for HCQIA Immunity. Presented by:Kimberly Daniel,JD 2011 NAMSS Convention Summarized by : Lillian E. Zamora, MAEd. The Act.
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2011 NAMSS Convention
Summarized by: Lillian E. Zamora, MAEd
TheHealthcareQualityImprovementact of 1986(“HCQIA”) providesinmunityfrom civil moneydamagestohospitlas, clinics, physicians and othersparticipating in “professionalreviewactions” so long as certainrequirements are met. Theserequirements are sometimesreferredto as the “fairnessstandardsorelements of
HCQIA immunityisnotfromsuititobviouslyisveryimportant . If HCQIA immunityisavailable , theonlyremedythatmaybeawardedto a succesfulplantiffisaninjunction.
Thispresentationwillprovideguidanceonhowhealthcareorganizationsmaybestestablish and retain HCQIA immunitybasedonlesonslearnedfromrecent HCQIA cases
1. Overview of HCQIA
A. Purpose of theact
B. Summary of theact
C. Beneficiaries of theact
2. Lessonslearnedfrom cases WhereImmunityWasLost
3. Crucial FactorstoEnsureEstablishment and Retention of Immunity
One of thegoals of theUnitedStatesCongress in enacting HCQIA wastodevelop a repositorythatcontainedthenames of physiciansagainstwhomprofessionalsreviewactionsweretaken, malpracticejudgementsentered,andsettlementsreached.
Notalltypes of healthcareprovidersmustbereported.
Thetrade off forstablishingthisdatabase, TheNationalPractitionerDatabank (“NPDB”), istheimmunityforparticipants in prfessional peer reviewactions. HCQIA immunityisintendedtopromoteparticipation, candor, and objectivity in thecriticalevaluation of medicalprofessionalsbymedicalprofessionalswhichisnecessaryfortheefficacy of thereviewprocess.
Under HCQIA, healthcareentities and coveredindividualsmayqualifyforimmnunityfrom civil monetarydamagesforcertainactionsifthereprotinformationtothe NPDB following a professionalreviewactionthatadverselyaffectsthclinicalprivileges of a physicianfor a periodlongerthan 30 days.
Summary of HCQIA
HCQIA immunityappliesif a professionalreviewactionistaken:
In thereasoablebeliefthtatheactionwas in thefurtherance of qualityhealthcare.
After a reasonableefforttoobtainthefacts of thematter.
Afteradequatenotice and hearingprocedures are affordedtothephysicianinvolvedoraftersuchotherprocedure as are fairtothephysicianunderthecircumstances, and
In thereasonablebeliefthtattheactionwaswarrantedby te factsknownaftersuchreasonableefforttoobtainfactsaftermeetingtherequirements of paragraph (3)
Twotypes of noticemustbegiventoestablish HCQIA immunity:
1. Notice of proposedaction, and
2. Notice of hearing
Notice of proposedactionmuststate;
1. That a professionalreviewaction has beenproposedtobetakenagainst a phsysician;
3.The pyscian has thereghttorequest a hearing
4. Any time limitstorequest a hearing (notlessthan 30 days);and
5. A summary of thephysican’sharingrigthsthatcomplywith HCQIA.
Ifthephysicantimelyrequests a haring, he mustbegiven a noticestating:
1.The place, time and date of thehearing , whichisnotlessthan 30 daysafterthedte of thenotice; and
2. thelist of whitnesses(ifany) expectedtotestifyonbehalf of theprofessionalreviewbody.
AdequateNotice and HearingProcedures
Hearingbefore and adjudication panel;
Hearingofficcermaynotbeaneconomiccompetitor of physican;
Panel participannstsmaynotbeaconmiccopetitors of physican;
Record of procedings;
6. Call, examine, crosswitness;
8.Provide a writtenstatement at theconclusion of theprocedings;
9. Righttoreceive a writtendecsion of the panel, includingstatements of thereasonsforitsrecommendations;and
10.Righttoreceivewrittendecision of thehealthcareentity, incluidngthebasisforthedecision.
A healthcareentitymaytake a profewssionalreviewactionwhichresults in animmediatesuspensionorrestriction of a physician’sclinicalprivilegeswithout prior niticeorhearingwherefailuretoactmayresultimminentnotice and hearingorotheradequateprocedures.
Coveredhealthcareentitiesstartwithbenefit of thedoubt
HCQIA expressly presumes thatall of itsrequirementsforimmunityweremet prior tothereviewactionbeingtaken.. Thispresumptionhowever, mayberebuttedby a preponderance of theevidence.
Great deferenceisaffordedthereviewactionanddecisionmade so long as there are soomefactstosupportit AND theactiontakenfollowedthe HCQIA statutorycriteria in sequence.
HCQIA doesnotrequirethat a professionalreviewactionresult in an actual improvement in thequality of healthcarenordoesitrequirethattheconclusionsreachedbythereviewersbecorrect …justthatthereviewactionbereasonable.
In determiningwether HCQIA immunityisavailableto a defendant, thecourtswillmakeanobjectivereview as towhetherthefour (4) requirementsweremet. HCQIA immunitywillbegrantedonlywhenit can beshownthattheactiontakenwas;
√In thefurtherance of qualityhealthcare
√Followed a fact-findinginvestigation of somekind.
√Followedproceduralrights of notice and a hearing (ortheequivlaentthreof);and
√ waswarrantedbasedonthefactsobtainedbefore and afterthehearing.
Whobenefitfrom HCQIA immunity?
▶Anymember of a professionalreviewbody
With legal protectionhowis HCQIA immunityeverlost?. Ifanyone of the4requirementsisabsent;
1.An actionnottaken in furtherance of quality of healthcare;
2. Actionthatdidnotfollow a factual investigation;
3. And actionthatfailedtoprovidetheaffectedphysicantheproceduralrights; or
4. Anactionthatwasnotwarrantedbaseduponthe factual information.
Most of the cases thatfollowfailedtosatisfy more thanone HCQIA requirement. Allweredecidedon a failuretomeetthemostobjective HCQIA requirement: absence of notice and oportunityforhearing (dueprocessgrounds)Thebigtakeway: Ensurepropernotice and hearingproceduresfollowed. Thisisthekeyto a succesful HCQIA immunitydefense.
Most of the cases thatfollowfailedtosatisfy more thanone HCQIA requirement. Allweredecidedon a failuretomeetthemostobjective HCQIA requirement: absence of notice and oportunityforhearing (dueprocessgrounds)
Thebigtakeway: Ensurepropernotice and hearingproceduresfollowed. Thisisthekeyto a succesful HCQIA immunitydefense.
ReviewActionWasNot in Furtherance of theQuality of HealthCare
In virtuallyevery dispute in whichthedefendantscalim HCQIA immunity, thereis a dispute as towethertheactionwasfurtherance of “ thequality of healthcare”.
ReviewActionWasNot in Furtherance of theQuality of HealthCare
Evenwhencourtsacknowledcgefactsthatsuggestother motives fortherevewaction, mostcourts do not base theirdecisionsabout HCQIA immunityontheabsence of thisrequirements.
Seeenclosed PDF file:
Review Action Was Not in Furtherance of the Quality of Health Care