New Landmark Illinois Law Caps Hospital Charges to Uninsured

The new landmark Illinois law, the Hospital Uninsured Patient Discount Act, became effective on April 1, 2009. Under the Act, hospitals may charge uninsured patients no more than the cost of services they received plus 35 percent. In addition, hospitals may collect no more than 25 percent of a patient's family income from an eligible uninsured patient during a 12-month period. According to the office of Illinois Attorney General Lisa Madigan, on average hospitals have charged uninsured patients up to 200 percent more than the cost of services. Eligible uninsured patients include those that are within 600 percent of the Federal Poverty Level ($132,300 for a family of four in 2008) at non-rural hospitals and 300 percent of the Federal Poverty Level ($66,150 for a family of four in 2008) at rural and critical access hospitals. The new law will be enforced by the Attorney General. That office has also collaborated with Illinois hospitals to assist them in calculating their cost-to-charge ratios and will work to ensure that eligible patients have access to that information. For more information, please click here.

Court Upholds Immunity Under HCQIA for Hospital

The U.S. Circuit Court of Appeals for the Fourth Circuit recently held that a hospital was immune from various federal and state claims under the Health Care Quality Improvement Act of 1986 (HCQIA) for suspending a physician's privileges without a hearing (Wahi v. Charleston Area Medical Center). In this case, Dr. Wahi, a cardiothoracic surgeon, had a long disciplinary history with Charleston Area Medical Center (CAMC), in West Virginia. After several temporary suspensions, CAMC chose to deny Dr. Wahi's request to reinstate his clinical privileges. CAMC alerted Dr. Wahi of his right to have a hearing but failed to schedule one. As required under law, the hospital reported Dr. Wahi's suspensions to the National Practitioner Data Bank, a clearinghouse established under HCQIA. As a result, Dr. Wahi brought an action in federal court alleging, among other things, antitrust, breach of contract and civil rights violations.

The court noted that the HCQIA provides a "professional review body" with immunity from damages whenever a "professional review action" is taken:

  1. in the reasonable belief that the action was in the furtherance of quality health care;
  2. after a reasonable effort to obtain the facts of the matter;
  3. after adequate notice and hearing procedures are afforded to the physician involved or after such other procedures that are fair to the physician under the circumstance; and
  4. in the reasonable belief that the action was warranted by the facts known after such reasonable effort to obtain facts and after meeting the requirement of paragraph 3.

Under HCQIA, health care entities may also qualify for immunity from civil liability for certain disciplinary actions if they report information to the data bank.

After an extensive review of the HCQIA, the Fourth Circuit affirmed the district court's ruling and concluded that because CAMC's actions qualified as a professional review, the hospital was entitled to immunity under HCQIA, despite not having held a formal hearing. The court determined that CAMC satisfied the third prong of the immunity test by affording Dr. Wahi "other procedures" that were fair under the circumstances, such as providing a detailed letter regarding his rights and providing notice of the action and charges against him.

HHS Publishes Guidance for Breach Notification

The Department of Health and Human Services (HHS) recently published guidance on technologies and methodologies to secure health information, as required by the American Recovery and Reinvestment Act of 2009 (ARRA). The guidance provides steps that entities can take to secure personal health information in compliance with new ARRA requirements for the Health Insurance Portability and Accountability Act (HIPAA) and establishes the trigger for sending patients a notice that their data has been compromised. This guidance is related to two "breach notification" regulations, one to be issued by HHS and the other recently published by the Federal Trade Commission (see below). The HHS regulations will address covered entities (such as hospitals and other providers) while the FTC regulations apply to vendors of personal health records and other organizations not covered by HIPAA. The guidance must be updated annually. In addition to this guidance, HHS has also issued a request for information (RFI) soliciting public comment on the breach notification provisions of ARRA to inform future rulemaking and updates to the guidance. Once published in the Federal Register, the guidance and RFI will also be available for public comment.

FTC Publishes Proposed Breach Notification Rule for Electronic Health Information

The FTC announced that it has approved a Federal Register notice seeking public comment on a proposed rule requiring certain vendors of personal health records and related organizations to notify consumers when the security of their electronic health information has been breached. The ARRA requires HHS to conduct a study and report, in consultation with the FTC, on potential privacy, security and breach notification requirements for vendors of personal health records and related entities. The study/report must be completed by February 2010. While the study/report is being completed, the FTC has issued a temporary rule that stipulates that if a service provider to one of these entities experiences a breach, it must notify the entity, which, in turn, must notify consumers of the breach. The rule also details the timing, method and content of the notice. It also requires entities to notify the FTC of any breaches so the FTC may post the information on its website and notify HHS.

Medicare Expands Coverage of PET Scans as Cancer Diagnostic Tool

Based on evidence collected from a National Oncologic PET Registry (NOPR) observational study, the Centers for Medicare & Medicaid Services (CMS) has issued a national coverage determination (NCD) that expands Medicare coverage for positron-emission tomography (PET) scans used to support initial diagnosis and treatment for most types of solid tumor cancers. The NCD also expands coverage for follow-up testing for certain cancers. The NCD removes a requirement that providers report data to the NOPR for these cancers, but does not remove the requirement that providers report data to the NOPR when using PET scans to monitor treatment progress or remission of cancer in certain cases. More information on the NCD can be found here.

Source: Health Law Regulatory Update