Peer Review: How HCQIA Due Process is a Fiction

HCQIA Due Process Rights are a Fiction in Most Cases

(August 31, 2014): The Healthcare Quality Improvement Act of 1986[1] (“HCQIA”, generally pronounced “Hick Kwah”), affords peer-reviewing bodies and their members legal immunity from liability from suits by the physicians they discipline, so long as their peer-review processes include certain due process rights for the accused physician. Unfortunately, the provider peer review process is irrevocably broken. HCQIA due process safeguards intended to protect the rights of physicians, nurse practitioners, physician assistants and other medical professionals simply doesn't work. If you have worked as a licensed professional for more than a few years, you likely know one or more physicians or other medical professionals who will readily share their stories of how the "system" is rigged in favor of the institution. This article provides an overview of HCQIA and outlines several sad realities of what you should expect if you are called before a peer review committee. It also emphasizes the fact that you should engage qualified legal counsel at your earliest opportunity in the process so that you can achieve the most favorable outcome possible.

I. Overview of HCQIA Due Process Rights:

Under HCQIA, a physician’s due process rights are typically expressed as a right to a hearing, and are generally outlined in a hospital staff’s bylaws. Most hospitals in the United States have structured the process so that a physician’s hearing and other due process rights arise only after a decision on the merits of the discipline case have been made, and therefore exist only at what is functionally an appeal level. At this later stage, any decision in the physician’s favor requires a finding of abuse of discretion or bad faith, and a heavy burden of proof is placed on the physician. So the due process rights in practice arise only after the point in the peer review when they can be of most benefit to the physician.

II. HCQIA and Peer Review:

Congress enacted HCQIA in 1986 purportedly to prevent a misbehaving physician from traveling to a new state, thereby possibly escaping notice of professional discipline actions taken against them [2]. The heart of HCQIA is a mandatory national reporting scheme and database. Hospitals, their medical staffs, state medical boards and other bodies which discipline clinicians are required to report serious professional sanctions imposed by them to a nationwide database named the National Provider Data Bank[3], or “NPDB”. This database is accessible to other hospitals and boards, insurance carriers and other payers, and most institutions which hire and fire physicians[4]; and as contemplated by Congress, such persons now routinely consult the National Practitioner Data Bank (NPDB) to look for a history of professional discipline before recruiting any clinician or granting privileges.

A feature of HCQIA is a grant of legal immunity to the bodies that conduct peer review of medical professionals, and their members, against legal liability for adverse actions they may take against the professionals in peer review proceedings, so long as the proceedings conform to certain basic due process requirements described in the statute. This legal immunity is so desirable that within a short time after enactment of the HCQIA legislation, hospital staffs and other peer reviewing bodies around the country revised their bylaws and other constituent documents to conform to HCQIA’s due process requirements and thus secure immunity. These procedures are normally set down in the hospital’s staff bylaws, and afford the affected physician a hearing where the due process rights apply. The bylaw provisions which set out this process and these rights have become notably uniform across the US.

III. HCQIA Standards for Peer Review Actions:

Under HCQIA, hospitals may undertake a “professional review action”[5] against a physician alleged with misconduct or incompetence. This is any formal action can adversely affect the physician’s clinical privileges or membership in a professional society, and generally includes any adverse outcome in any serious physician peer review action. Any such action must be based on the recommendations[6] of a “professional review body”, which is normally the hospital’s medical staff or a committee appointed by it to conduct peer review activity.

If the affected physician requests it, he or she must be afforded certain due process rights, in the form of a hearing. The hearing must be held before an independent intermediary such as a mutually acceptable arbiter, a hearing officer, or a panel of individuals appointed by the hospital but who are not in direct economic competition with the physician involved. In the hearing process the physician has the right to be represented by legal counsel, receive a statement of all charges against him, present evidence, and call, examine, and cross-examine witnesses. The physician may also submit a written statement at the close of the hearings and have a record made of the proceedings. At the conclusion of the hearing, the physician then has the right to receive the written recommendation of the arbitrator, officer, or panel, including a statement of the basis for the recommendations. Only if the professional review body follows these standards will it and its members receive immunity from damages under the law.

IV. A Lack of "Real" HCQIA Due Process Rights Has Resulted in a System that is Fundamentally Unfair:

On its face, this process appears to provide the affected physician with adequate due process rights in his peer review. The statute states that any professional review action cannot be taken until after adequate notice and hearing procedures have been afforded to the doctor. In practice, however, the due process rights arise only at a point when they are of little use.

In the common form of peer review adjudication process provided under staff bylaws written to conform to HCQIA, after receiving complaints about a particular physician or otherwise having professional conduct brought into question, the medical staff, acting through its executive committee, will appoint an investigative or “ad hoc” committee to conduct an investigation into the matter and make a recommendation to the executive committee, which in turn will make a recommendation to the hospital board, about how the matter should be resolved. While technically neither is the executive committee bound to conform to the ad hoc committee’s recommendation, nor is the hospital board bound to conform to the executive committee’s recommendation, in practice most such recommendations are accepted. While these committees are charged to act as fact-finders, their authority normally goes much further, and they are empowered to restrict, suspend, revoke, or otherwise adversely affect the doctor’s privileges during the pendency of their proceedings. HCQIA is drafted so that the due process rights it requires are not obviously applicable to these ad hoc committee and executive committee stages of the peer review process, which amount to the merits determination point in the case. Modern staff bylaws invariably take advantage of this, and list several due process rights which the accused does not have at these stages, and are otherwise silent on what rights he does have at these stages.

Therefore, under most staff bylaws, by the time the accused can request a hearing before a professional review body and enjoy the basic due process rights mandated by HCQIA, the actual decision on his clinical privileges has already been made. Most bylaws make the hearing before a professional review body into nothing more than an appeal right, with grounds for review that are not a decision on the merits of the peer review decision. For the physician to prevail, most bylaws require a showing of absence of an evidentiary basis for the decision, or some form of bad faith. The standard is similar to that applied in a Federal court’s review of an administrative law judge’s decision. Most bylaws also impose the burden of proof on the accused, requiring that the affected physician to make his case by a preponderance of evidence. The process is carefully structured so the due process rights enumerated in HCQIA are not in effect when the actual merits of the peer review case are decided.

V. Final Remarks:

The common form of medical staff bylaws create a procedure where an accused physician enjoys due process rights only at a stage when they can be of little or no use. The ad hoc committee of the hospital medical staff, and its executive committee, are in practice free to make determinations about medical staff privileges entirely without the basic procedural and related rights for the accused normally considered necessary for fundamental fairness. The list of HCQIA due process rights you supposedly have creates an illusion of fair process. But as actually employed, they are nearly useless to the accused.

In light of the above, an accused physician needs to avoid the comfortable fiction that the stages of peer review at the committee level are non-final, and a meaningful hearing with actual due process rights exists at a later stage. The hearing stage in modern peer review is hopelessly weighted against the accused, and once that stage is reached his fate in normally sealed. When a physician finds him or herself in the committee stage of peer review, all their efforts and resources need to be deployed. While most bylaws forbid an accused physician from bring counsel to committee “meetings” at the committee stage, they cannot prevent his consulting and taking advice from experienced counsel, and the prudent physician will do just that. If he waits to engage counsel for the hearing stage, it is probably too late. For a free consultation, call David at: 1 (800) 475-1906

David Parker Healthcare Lawyer
David Parker serves as Managing Partner at Liles Parker, PLLC, a boutique health care practice with offices in Washington, DC, Baton Rouge, LA, Houston, TX and McAllen, TX. David represents health care providers and suppliers around the country in peer reviews, post-payment audits, prepayment reviews, and enrollment suspension and revocation actions. Do you have a question regarding any of the above? If so, please give David a call for a complimentary consultation. He can be reached at: 1 (800) 475-1906.
  • [1] 42 U.S.C. §§ 11101 – 11152.
  • [2] The Congress finds …(t)here is a nationwide need to restrict the ability of incompetent physicians to move from State to State without disclosure or discovery of the physician’s previous damaging or incompetent performance.” 42 USC §11101(3)
  • [3] The data bank was given its name and current form in HHS regulations adopted under HCQIA and codified at 45 CFR §60.1.
  • [4] The NPDB is not, however, accessible to direct consumers of medical services i.e. the general public.
  • [5] HCQIA defines “professional review action” as “an action or recommendation of a professional review body which is taken or made in the conduct of professional review activity, which is based on the competence or professional conduct of an individual physician (which conduct affects or could affect adversely the health or welfare of a patient or patients), and which affects (or may affect) adversely the clinical privileges, or membership in a professional society, of the physician. Such term includes a formal decision of a professional review body not to take an action or make a recommendation described in the previous sentence and also includes professional review activities relating to a professional review action.” § 111151(9).
  • [6] HCQIA contemplates the existence of a medical staff at hospitals and other provider institutions, which is the body of all licensed clinicians practicing at the institution. Although it is something of a legal fiction, as most medical staffs are not incorporated and aren’t otherwise legal persons, HCQIA treats the medical staff as a legal person to whom certain tasks are delegated by the hospital, namely the administration and adjudication of professional quality control in the form of peer reviews. The medical staff in turn appoints a committee to perform its adjudications. But since the hospital’s board is normally the only body with actual legal authority to perform a peer review act like termination of privileges, HCQIA, and therefore most bylaws written with HCQIA in mind, couch the decision-making of the medical staff as a recommendation to the hospital’s board of directors.