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Presented by:Kimberly Daniel,JD 2011 NAMSS Convention Summarized by : Lillian E. Zamora, MAEd - PowerPoint PPT Presentation

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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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HCQIA InmunityLessonslearned:AnAnalysis of Recent Cases WhereHospitals and IndividualsLostTheirBidfor HCQIA Immunity


2011 NAMSS Convention

Summarized by: Lillian E. Zamora, MAEd

The act


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

42 U.S.C.∲111129(a)”.

The act1


HCQIA immunityisnotfromsuititobviouslyisveryimportant . If HCQIA immunityisavailable , theonlyremedythatmaybeawardedto a succesfulplantiffisaninjunction.

Thispresentationwillprovideguidanceonhowhealthcareorganizationsmaybestestablish and retain HCQIA immunitybasedonlesonslearnedfromrecent HCQIA cases

Learning objectives


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

4. Questions

Purpose of hcqia

Purpose of HCQIA

One of thegoals of theUnitedStatesCongress in enacting HCQIA wastodevelop a repositorythatcontainedthenames of physiciansagainstwhomprofessionalsreviewactionsweretaken, malpracticejudgementsentered,andsettlementsreached.


Notalltypes of healthcareprovidersmustbereported.

Purpose of hcqia1
Purpose of HCQIA

Thetrade off forstablishingthisdatabase, TheNationalPractitionerDatabank (“NPDB”), istheimmunityforparticipants in prfessional peer reviewactions. HCQIA immunityisintendedtopromoteparticipation, candor, and objectivity in thecriticalevaluation of medicalprofessionalsbymedicalprofessionalswhichisnecessaryfortheefficacy of thereviewprocess.

Summary of hcqia

Summary of HCQIA

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)


Adequate notice and hearing procedures
AdequateNotice and HearingProcedures

Twotypes of noticemustbegiventoestablish HCQIA immunity:

1. Notice of proposedaction, and

2. Notice of hearing

Adequate notice and hearing procedures1
AdequateNotice and HearingProcedures

Notice of proposedactionmuststate;

1. That a professionalreviewaction has beenproposedtobetakenagainst a phsysician;

2. Thereasonsfortheproposedaction

3.The pyscian has thereghttorequest a hearing

4. Any time limitstorequest a hearing (notlessthan 30 days);and

5. A summary of thephysican’sharingrigthsthatcomplywith HCQIA.


Adequate notice and hearing procedures2

AdequateNotice and HearingProcedures

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;

Cont adequate notice and hearing procedures

cont. AdequateNotice and HearingProcedures

6. Call, examine, crosswitness;

7.Present evidence;

8.Provide a writtenstatement at theconclusion of theprocedings;

9. Righttoreceive a writtendecsion of the panel, includingstatements of thereasonsforitsrecommendations;and

10.Righttoreceivewrittendecision of thehealthcareentity, incluidngthebasisforthedecision.


Summary of hcqia1

Summary of HCQIA


A healthcareentitymaytake a profewssionalreviewactionwhichresults in animmediatesuspensionorrestriction of a physician’sclinicalprivilegeswithout prior niticeorhearingwherefailuretoactmayresultimminentnotice and hearingorotheradequateprocedures.


Summary of hcqia2
Summary of HCQIA

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.


  • In otherwords, courtsgenerallywillnotsustitutetheirjudgementforthose of theparticipatingentity and individuals.

  • Participantsmaynotsupply false information, but…. “Thegoodorbadfaith of thereviewersisirrelevant.

  • Broder vs. Allegany

Summary of hcqia3

Summary of HCQIA

HCQIA doesnotrequirethat a professionalreviewactionresult in an actual improvement in thequality of healthcarenordoesitrequirethattheconclusionsreachedbythereviewersbecorrect …justthatthereviewactionbereasonable.


Summary of hcqia4

Summary of HCQIA

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.

Beneficiaries of the act

Whobenefitfrom HCQIA immunity?


▶Hospital Administrators



▶Anymember of a professionalreviewbody

▶ Thepublic

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.

HCQIA immunityalsomustbeexpresslyclaimed

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.

Review action was not in furtherance of the quality of health care
ReviewActionWasNot in Furtherance of theQuality of HealthCare

  • Remember, thecourtsreviewunder HCQIA isanobjectivereview

  • A determinationthatreviewactionwasnottaken “ in furtherance of thequality of healthcare” wouldlikelyrequirecourtstomakesubjectivefindings-whichmost are willingto do.

Seeenclosed PDF file:

Review Action Was Not in Furtherance of the Quality of Health Care

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