The Health Care Quality Improvement Act of 1986 (HCQIA) establishes certain “core” due process requirements which a hospital must follow in an internal disciplinary process involving a physician. That discipline can include termination of membership in the medical staff and revocation of clinical privileges. Learn more about these procedural HCQIA requirements and and their importance when it comes to a medical staff hearing.
HCQIA Requirements for a Medical Staff Hearing
To satisfy the HCQIA “standards for professional review actions” (§11112), the hospital must provide the physician with adequate notice and hearing, including:
- Notice of proposed action – Physician is advised of the proposed action (e.g. suspension, termination, revocation of privileges), the right to a hearing and any time limits for holding a hearing and the physician’s hearing rights.
- Notice of hearing – Place/date/time of hearing (not less than 30 days after date of notice of proposed action) with a list of any witnesses to testify at the hearing, etc.
- Conduct of hearing and notice
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- Hearing shall be held before an arbitrator; a hearing officer who is appointed by the entity and who is not in direct economic competition with the physician; or a panel of individuals who are appointed by the entity and are not in direct economic competition with the physician.
- During the hearing, the physician has the right to representation by an attorney or other person of the physician’s choice; have the proceedings recorded; call, examine, and cross-examine witnesses; present evidence determined to be relevant by the hearing officer, regardless of its admissibility in a court of law; and to submit a written statement at the close of the hearing.
- Upon completion of the hearing, the physician has the right to receive the written recommendation of the arbitrator, hearing officer or panel.
Additional Bylaw Requirements 
Medical Staff Bylaws often contain even more detailed procedural requirements than the HCQIA. Some of the additional requirements are set forth in the Pennsylvania Code. This is critically important since Medical Staff Bylaws are considered to create a contractual relationship between each member of the medical staff and the hospital. If a hospital violates its own bylaws, a physician can and has initiated a cause of action for breach of contract challenging the result of the disciplinary process. This could entitle the physician to injunctive relief.
Accordingly, hospitals cannot simply focus on the requirements of HCQIA. Rather, hospitals must satisfy the procedural safeguards set forth in their bylaws to avoid claims by physicians that they were not treated fairly or given a full opportunity to be heard.
There are cases in Pennsylvania such as Berberian v. Lancaster Osteopathic Hosp. Association, Inc. and Miller v. Indiana Hospital which suggest that a hospital will be held to a standard of strict compliance with its own bylaws. However, after some analysis, Miller then suggested that certain “de minimis deviations” that do not result in material prejudice to the physician may not entitle the physician to relief.
In Lang v. The Allentown Hospital, the court evaluated a series of alleged procedural defects and bylaw deviations which occurred during the investigative process. However, the court ultimately determined that in order to grant a physician relief, a hospital’s failure to comply with its bylaws must be material and result in a substantial denial of the benefits of the (contractual) bargain. The court, and other courts, have focused on whether or not, when viewed in the totality of the process, the defects precluded the physician from an overall fair review process.
Legal support for medical staff hearings and beyond
It is important to note, however, that in each case in which procedural deficiencies are identified, a court engages in a fact-finding process to determine the impact of the defects on the physician’s right to an impartial and fair internal review process. Accordingly, it is critically important for a hospital and its medical staff to seek compliance with each and every aspect of the bylaws. Anything less than full compliance places the institution at risk. From the physician’s perspective it is important to fully evaluate the investigative and hearing process and identify any defects in that process.
At FLB, our healthcare attorneys in Allentown, PA understand the unique needs of our medical staff and physician clients and have the knowledge and experience to meet ever-changing accreditation, regulatory and statutory requirements. To support our clients’ varying medical relationships, we frequently develop bylaws, peer review protected processes, and fair hearing and appellate review procedures. We also regularly assist physicians with navigating the corrective action, fair hearing and appellate review processes to ensure compliance with bylaws, regulatory and statutory requirements.
