Risk Management and Legal Issues
HCQIA protection
The Health Care Quality Improvement Act of 1986 provides limited immunity from damages for professional review actions when four conditions are met: the action furthers quality health care and the reviewers reasonably believe so; the reviewers make a reasonable effort to obtain the facts; the practitioner receives adequate notice and hearing procedures; and the reviewers reasonably believe the action is warranted by the facts. Immunity is not absolute and does not cover civil rights or antitrust claims.
Reporting and due process
Hospitals must report to the NPDB professional review actions that adversely affect clinical privileges for more than 30 days, and malpractice payments. Due process typically includes written notice of the proposed action, a hearing, representation, a record, and an appeal. State peer review statutes supply confidentiality and some immunity; they vary.
Worked example
A practitioner's privileges are suspended for 45 days pending review. Reasoning: the action exceeds 30 days, so it is reportable to the NPDB unless it meets a narrow exception. Because it adversely affects privileges, the fair hearing plan is triggered. The file must show notice, hearing, and a reasoned decision. A 20-day suspension, by contrast, generally falls below the reporting threshold, though internal policy may still require review.
Traps that cost marks
Thinking peer review immunity is absolute; reporting only permanent revocations; overlooking antitrust exposure in exclusionary peer review (Patrick v. Burget); missing negligent credentialing theories (Johnson v. Misericordia); and handling notice or hearing defects informally.