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

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

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  1. HCQIA InmunityLessonslearned:AnAnalysis of Recent Cases WhereHospitals and IndividualsLostTheirBidfor HCQIA Immunity Presentedby:KimberlyDaniel,JD 2011 NAMSS Convention Summarized by: Lillian E. Zamora, MAEd

  2. TheAct 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)”.

  3. TheAct HCQIA immunityisnotfromsuititobviouslyisveryimportant . If HCQIA immunityisavailable , theonlyremedythatmaybeawardedto a succesfulplantiffisaninjunction.

  4. Thispresentationwillprovideguidanceonhowhealthcareorganizationsmaybestestablish and retain HCQIA immunitybasedonlesonslearnedfromrecent HCQIA cases

  5. LearningObjectives 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

  6. Purpose of HCQIA One of thegoals of theUnitedStatesCongress in enacting HCQIA wastodevelop a repositorythatcontainedthenames of physiciansagainstwhomprofessionalsreviewactionsweretaken, malpracticejudgementsentered,andsettlementsreached. 42U.S.CS.∲11101et.seg. Notalltypes of healthcareprovidersmustbereported.

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

  8. Summary of HCQIA Under HCQIA, healthcareentities and coveredindividualsmayqualifyforimmnunityfrom civil monetarydamagesforcertainactionsifthereprotinformationtothe NPDB following a professionalreviewactionthatadverselyaffectsthclinicalprivileges of a physicianfor a periodlongerthan 30 days. 42U.S.C.∲11133(1)(A)

  9. 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) 42U.S.CS.∲11112(a)

  10. AdequateNotice and HearingProcedures Twotypes of noticemustbegiventoestablish HCQIA immunity: 1. Notice of proposedaction, and 2. Notice of hearing

  11. 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. 42U.S.C.∲11112(b)(2)

  12. 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. 42U.S.C.∲11112(b)(2)

  13. AdequateNotice and HearingProcedures Thephysicanmusthavethefollowinghearingrights: Hearingbefore and adjudication panel; Hearingofficcermaynotbeaneconomiccompetitor of physican; Panel participannstsmaynotbeaconmiccopetitors of physican; Representationbyattorney; Record of procedings;

  14. 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. 42U.S.C.∲11112(c)(2)

  15. Summary of HCQIA EmergencySituations A healthcareentitymaytake a profewssionalreviewactionwhichresults in animmediatesuspensionorrestriction of a physician’sclinicalprivilegeswithout prior niticeorhearingwherefailuretoactmayresultimminentnotice and hearingorotheradequateprocedures. 42U.S.C.∲11112(c)(2)

  16. 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. 42U.S.C.∲11112(2)(a)

  17. In otherwords, courtsgenerallywillnotsustitutetheirjudgementforthose of theparticipatingentity and individuals. • Participantsmaynotsupply false information, but…. “Thegoodorbadfaith of thereviewersisirrelevant. • Broder vs. Allegany

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

  19. 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.

  20. BENEFICIARIES OF THE ACT Whobenefitfrom HCQIA immunity? ▶Hospitals ▶Hospital Administrators ▶Physicians ▶Nurses ▶Anymember of a professionalreviewbody ▶ Thepublic

  21. 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

  22. RECENT CASES IN WHICH HCQIA IMMUNITY WAS LOST

  23. 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.

  24. 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.

  25. ReviewActionWasNot in Furtherance of theQuality of HealthCare In virtuallyevery dispute in whichthedefendantscalim HCQIA immunity, thereis a dispute as towethertheactionwasfurtherance of “ thequality of healthcare”.

  26. ReviewActionWasNot in Furtherance of theQuality of HealthCare Evenwhencourtsacknowledcgefactsthatsuggestother motives fortherevewaction, mostcourts do not base theirdecisionsabout HCQIA immunityontheabsence of thisrequirements.

  27. ReviewActionWasNot in Furtherance of theQuality of HealthCare • Remember, thecourtsreviewunder HCQIA isanobjectivereview • A determinationthatreviewactionwasnottaken “ in furtherance of thequality of healthcare” wouldlikelyrequirecourtstomakesubjectivefindings-whichmost are willingto do.

  28. Seeenclosed PDF file: Review Action Was Not in Furtherance of the Quality of Health Care Related Cases

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