Recent Developments in HCQIA
Immunity
During the past year, there have been numerous developments involving physician and hospital immunity from monetary damages for claims arising out of the peer review process under the Health Care Quality Improvement Act (HCQIA). These recent interpretations of the statute can be beneficial in providing guidance to physicians and hospitals in implementing peer review policies and procedures.
Congress enacted the HCQIA to improve the quality of medical care by encouraging physicians to identify and discipline other physicians who are incompetent or who engage in unprofessional behavior. HCQIA provides immunity from monetary damages for a professional review body engaged in a professional review action if the professional review action is taken: (1) in the reasonable belief that the action was in furtherance of quality health care; (2) after a reasonable effort to obtain the facts; (3) after adequate notice and hearing procedures are afforded to the physician; and (4) in the reasonable belief that the action was warranted by the facts known after such reasonable effort to obtain facts.[1] HCQIA creates a rebuttable presumption in favor of immunity. In order to rebut the presumption, the plaintiff must establish by a preponderance of the evidence that the defendant does not comply with the requirements. The following cases represent an overview of court decisions across the country involving HCQIA immunity.[2]
The Supreme Court of South Dakota held that HCQIA immunity applied to the informal meeting of physicians because the physicians were assisting the governing body in a professional review activity by discussing whether the plaintiff's surgical privileges should be modified in light of his recent manic episode.[3] The statutory definition of "professional review body" does not require the committee to be formal, appointed or elected, and any committee of the medical staff qualifies as a professional review body when assisting the governing body in a professional review activity.
The Missouri Court of Appeals discussed the availability of HCQIA immunity in the absence of an adverse action against the investigated physician. In Gateway Cardiology v. Wright, the defendant sent letters expressing concerns about another cardiologist performing medically unnecessary procedures; however, the peer review committee ultimately determined that the allegations were not supported and no adverse action was taken.[4] The court granted immunity to the defendant because HCQIA immunity is available even where an investigation yields no adverse action against the physician.
Courts have continued to find that HCQIA immunity applies not only in situations involving professional incompetence, but also in cases where physicians engage in disruptive conduct. In Curtsinger v. HCA, Inc., the plaintiff had multiple complaints filed against him involving his personal and professional interactions with patients and other employees, disruptive behavior, and failure to respond to three ER calls.[5] The court granted immunity to the defendants because quality health care includes both clinical competence and matters of general behavior and ethical conduct. The peer review committee could have reasonably believed that plaintiff's disruptive and unprofessional behavior would jeopardize the quality of health care at the hospital.
The following unpublished opinion discusses HCQIA immunity and public hospitals' ability to restrict their physicians' First Amendment rights. In Braswell v. Haywood Regional Medical Center, the court determined that HCQIA immunity applied to the plaintiff's breach of contract claim finding that the hospital had met the statutory requirements.[6] Regarding the plaintiff's retaliation claim based on termination of his employment, the court held the plaintiff's letter to the hospital's financing committee expressing disagreement with the hospital's recruiting efforts was not protected speech under the First Amendment. The court determined that the plaintiff was a public employee for purposes of First Amendment analysis because he held privileges to admit patients at the public hospital. In balancing the parties' interests, the court found that the plaintiff's interest in expressing concerns about hospital recruitment was outweighed by the hospital's interest in regulating speech that interferes with its' recruiting efforts, especially considering the hospital's sparsely populated location.
In Bakare v. Pinnacle Health Hospitals, Inc., the Fourth Circuit granted partial HCQIA immunity.[7] The HCQIA immunizes the professional review body from all damages claims which arise out of the peer review process.[8] A physician’s statement to nurses in the operating room lounge that the plaintiff was being investigated by the executive committee for substandard care of his patients did not arise out of the peer review process. Therefore, the court concluded that the HCQIA immunity applied to plaintiff's breach of contract claim, but the court denied immunity for the defamation claim stemming from this incident.
The Northern District of Iowa denied HCQIA immunity where the defendants did not undertake the professional review action after a reasonable effort to obtain facts and the plaintiff was not provided with adequate notice and hearing procedures.[9] The defendants did not provide the plaintiff with the information on which they based their professional review action in a timely manner and their investigation involved no effort to obtain facts contrary to this information. In addition, the plaintiff was not given the opportunity to appear at a hearing, present evidence in response to the allegations, or question witnesses. Therefore, the court denied HCQIA immunity for the defendants.
These recent cases illustrate the analyses courts undertake in examining the issues involved with HCQIA immunity and the facts on which the courts hinge their decisions. Although there is a presumption that the HCQIA immunity requirements have been met, these cases also illustrate that the presumption is not absolute and that there are instances where immunity is denied. This overview of state and federal cases can provide valuable information for hospitals and physicians involved in the peer review process.
For more information on HCQIA immunity or other credentialing issues, please contact Myra Selby, Sherry Fabina-Abney, or Lisa Gethers.
This publication is intended for general information purposes only and does not and is not intended to constitute legal advice. The reader must consult with legal counsel to determine how laws or decisions discussed herein apply to the reader's specific circumstances.