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1 | AN ACT concerning health care workers.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Health Care Worker Self-Referral Act is | |||||||||||||||||||||||||||||
5 | amended by changing Sections 5, 15, and 20 as follows:
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6 | (225 ILCS 47/5)
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7 | Sec. 5. Legislative intent. The General Assembly | |||||||||||||||||||||||||||||
8 | recognizes that
patient referrals by health care workers for | |||||||||||||||||||||||||||||
9 | health services
to an entity in which the referring health care | |||||||||||||||||||||||||||||
10 | worker has an investment
interest may present
a potential | |||||||||||||||||||||||||||||
11 | conflict of interest. The General Assembly finds that these | |||||||||||||||||||||||||||||
12 | referral
practices may limit or completely eliminate | |||||||||||||||||||||||||||||
13 | competitive alternatives in the health care
market. In some | |||||||||||||||||||||||||||||
14 | instances, these referral practices may expand and improve care
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15 | or may make services available which were previously | |||||||||||||||||||||||||||||
16 | unavailable. They
may also provide
lower cost options to | |||||||||||||||||||||||||||||
17 | patients or increase competition. Generally,
referral | |||||||||||||||||||||||||||||
18 | practices are positive occurrences. However, self-referrals | |||||||||||||||||||||||||||||
19 | may
result in over utilization of health services, increased | |||||||||||||||||||||||||||||
20 | overall costs
of the health care systems, and may affect the | |||||||||||||||||||||||||||||
21 | quality of health care.
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22 | It is the intent of the General Assembly to provide | |||||||||||||||||||||||||||||
23 | guidance to health
care workers regarding acceptable patient | |||||||||||||||||||||||||||||
24 | referrals, to prohibit patient
referrals to entities providing | |||||||||||||||||||||||||||||
25 | health services in which the referring
health care worker has | |||||||||||||||||||||||||||||
26 | an investment interest, and to protect the
citizens of Illinois | |||||||||||||||||||||||||||||
27 | from unnecessary and costly health care expenditures.
| |||||||||||||||||||||||||||||
28 | Recognizing the need for flexibility to quickly respond to | |||||||||||||||||||||||||||||
29 | changes in
the delivery of health services, to avoid results | |||||||||||||||||||||||||||||
30 | beyond the
limitations on self referral provided under this Act | |||||||||||||||||||||||||||||
31 | and to provide minimal
disruption to the appropriate delivery | |||||||||||||||||||||||||||||
32 | of health care, the Health
Facilities Planning Board shall be |
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1 | exclusively and solely authorized to
implement and interpret | ||||||
2 | this Act through adopted rules.
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3 | The General Assembly recognizes that changes in delivery of | ||||||
4 | health care has
resulted in various methods by which health | ||||||
5 | care workers practice their
professions. It is not the intent | ||||||
6 | of the General Assembly to limit
appropriate delivery of care, | ||||||
7 | nor force unnecessary changes in the
structures created by | ||||||
8 | workers for the health and convenience of their
patients.
| ||||||
9 | (Source: P.A. 87-1207.)
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10 | (225 ILCS 47/15)
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11 | Sec. 15. Definitions. In this Act:
| ||||||
12 | (a) "Board" means the Health Facilities Planning Board.
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13 | (b) "Entity" means any individual, partnership, firm, | ||||||
14 | corporation, or
other business that provides health services | ||||||
15 | but does not include an
individual who is a health care worker | ||||||
16 | who provides professional services
to an individual.
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17 | (c) "Group practice" means a group of 2 or more health care | ||||||
18 | workers
legally organized as a partnership, professional | ||||||
19 | corporation,
not-for-profit corporation, faculty
practice plan | ||||||
20 | or a similar association in which:
| ||||||
21 | (1) each health care worker who is a member or employee | ||||||
22 | or an
independent contractor of the group provides
| ||||||
23 | substantially the full range of services that the health | ||||||
24 | care worker
routinely provides, including consultation, | ||||||
25 | diagnosis, or treatment,
through the use of office space, | ||||||
26 | facilities, equipment, or personnel of the
group;
| ||||||
27 | (2) the services of the health care workers
are | ||||||
28 | provided through the group, and payments received for | ||||||
29 | health
services are treated as receipts of the group; and
| ||||||
30 | (3) the overhead expenses and the income from the | ||||||
31 | practice are
distributed by methods previously determined | ||||||
32 | by the group.
| ||||||
33 | (d) "Health care worker" means any individual licensed | ||||||
34 | under the laws of
this State to provide health services, | ||||||
35 | including but not limited to:
dentists licensed under the |
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1 | Illinois Dental Practice Act; dental hygienists
licensed under | ||||||
2 | the Illinois Dental Practice Act; nurses and advanced practice
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3 | nurses licensed under the Nursing and Advanced Practice Nursing | ||||||
4 | Act;
occupational therapists licensed under
the
Illinois | ||||||
5 | Occupational Therapy Practice Act; optometrists licensed under | ||||||
6 | the
Illinois Optometric Practice Act of 1987; pharmacists | ||||||
7 | licensed under the
Pharmacy Practice Act of 1987; physical | ||||||
8 | therapists licensed under the
Illinois Physical Therapy Act; | ||||||
9 | physicians licensed under the Medical
Practice Act of 1987; | ||||||
10 | physician assistants licensed under the Physician
Assistant | ||||||
11 | Practice Act of 1987; podiatrists licensed under the Podiatric
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12 | Medical Practice Act of 1987; clinical psychologists licensed | ||||||
13 | under the
Clinical Psychologist Licensing Act; clinical social | ||||||
14 | workers licensed under
the Clinical Social Work and Social Work | ||||||
15 | Practice Act; speech-language
pathologists and audiologists | ||||||
16 | licensed under the Illinois Speech-Language
Pathology and | ||||||
17 | Audiology Practice Act; or hearing instrument
dispensers | ||||||
18 | licensed
under the Hearing Instrument Consumer Protection Act, | ||||||
19 | or any of
their successor Acts.
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20 | (e) "Health services" means health care procedures and | ||||||
21 | services
provided by or through a health care worker.
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22 | (f) "Immediate family member" means a health care worker's | ||||||
23 | spouse,
child, child's spouse, or a parent.
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24 | (g) "Investment interest" means an equity or debt security | ||||||
25 | issued by an
entity, including, without limitation, shares of | ||||||
26 | stock in a corporation,
units or other interests in a | ||||||
27 | partnership, bonds, debentures, notes, or
other equity | ||||||
28 | interests or debt instruments except that investment interest
| ||||||
29 | for purposes of Section 20 does not include interest in a | ||||||
30 | hospital licensed
under the laws of the State of Illinois.
| ||||||
31 | (h) "Investor" means an individual or entity directly or | ||||||
32 | indirectly
owning a legal or beneficial ownership or investment | ||||||
33 | interest, (such as
through an immediate family member, trust, | ||||||
34 | or another entity related to the investor).
| ||||||
35 | (i) "Office practice" includes the facility or facilities | ||||||
36 | at which a health
care worker, on an ongoing basis, provides or |
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1 | supervises the provision of
professional health services to | ||||||
2 | individuals.
| ||||||
3 | ( j) "Referral" means any referral of a patient for health | ||||||
4 | services,
including, without limitation:
| ||||||
5 | (1) The forwarding of a patient by one health care | ||||||
6 | worker to another
health care worker or to an entity | ||||||
7 | outside the health care worker's office
practice or group | ||||||
8 | practice that provides health services.
| ||||||
9 | (2) The request or establishment by a health care
| ||||||
10 | worker of a plan of care outside the health care worker's | ||||||
11 | office practice
or group practice
that includes the | ||||||
12 | provision of any health services.
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13 | (Source: P.A. 89-72, eff. 12-31-95; 90-742, eff. 8-13-98.)
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14 | (225 ILCS 47/20)
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15 | Sec. 20. Prohibited referrals and claims for payment.
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16 | (a) A health care worker shall not refer a patient for | ||||||
17 | health services
to an entity outside the health care worker's | ||||||
18 | office or group practice in
which the health care worker is an | ||||||
19 | investor, unless the health care worker
directly provides | ||||||
20 | health services within the entity and will be personally
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21 | involved with the provision of care to the referred patient.
| ||||||
22 | (b) A health care worker making referrals to entities in | ||||||
23 | which he or she has an investment interest shall comply with 42 | ||||||
24 | U.S.C. 1395nn and accompanying regulations.
Pursuant to Board | ||||||
25 | determination that the following exception is
applicable, a | ||||||
26 | health care worker may invest in and refer to an entity,
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27 | whether or not the health care worker provides direct services | ||||||
28 | within said
entity, if there is a demonstrated need in the | ||||||
29 | community for the entity and
alternative financing is not | ||||||
30 | available. For purposes of this subsection
(b), "demonstrated | ||||||
31 | need" in the community for the entity may exist if (1)
there is | ||||||
32 | no facility of reasonable quality that provides medically
| ||||||
33 | appropriate service, (2) use of existing facilities is onerous | ||||||
34 | or creates
too great a hardship for patients,
(3) the entity is | ||||||
35 | formed to own or lease medical equipment which replaces
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1 | obsolete or otherwise inadequate equipment in or under the | ||||||
2 | control of a
hospital located in a federally designated health | ||||||
3 | manpower shortage area,
or (4) such other standards as
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4 | established, by rule, by the Board. "Community" shall be | ||||||
5 | defined as a
metropolitan area for a city, and a county for a | ||||||
6 | rural area. In addition,
the following provisions must be met | ||||||
7 | to be exempt under this Section:
| ||||||
8 | (1) Individuals who are not in a position to refer | ||||||
9 | patients to an
entity are given a bona fide opportunity to | ||||||
10 | also invest in the entity on the
same terms as those | ||||||
11 | offered a referring health care worker; and
| ||||||
12 | (2) No health care worker who invests shall be required | ||||||
13 | or encouraged
to make referrals to the entity or otherwise
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14 | generate business as a condition of becoming or remaining | ||||||
15 | an investor; and
| ||||||
16 | ( 3) The entity shall market or furnish its services to
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17 | referring health care worker investors and other investors | ||||||
18 | on equal terms; and
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19 | (4) The entity shall not loan funds or guarantee any | ||||||
20 | loans for health
care workers who are in a position to | ||||||
21 | refer to an entity; and
| ||||||
22 | (5) The income on the health care worker's investment | ||||||
23 | shall be tied to
the health care worker's equity in the | ||||||
24 | facility rather than to the volume
of referrals made; and
| ||||||
25 | (6) Any investment contract between the entity and the | ||||||
26 | health care
worker shall not include any covenant or | ||||||
27 | non-competition clause that
prevents a health care worker | ||||||
28 | from investing in other entities; and
| ||||||
29 | (7) When making a referral, a health care worker must | ||||||
30 | disclose his
investment interest in an entity to the | ||||||
31 | patient being referred to such
entity. If alternative | ||||||
32 | facilities are reasonably available, the health care
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33 | worker must provide the patient with a list of alternative | ||||||
34 | facilities.
The health care worker shall inform the patient | ||||||
35 | that they have the option to use
an alternative facility | ||||||
36 | other than one in which the health care worker has
an |
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1 | investment interest and the patient will not be treated | ||||||
2 | differently by
the health care worker if the patient | ||||||
3 | chooses to use another entity.
This shall be applicable to | ||||||
4 | all health care worker investors, including
those who | ||||||
5 | provide direct care or services for their patients in | ||||||
6 | entities
outside their office practices; and
| ||||||
7 | (8) If a third party payor requests information with | ||||||
8 | regard to a health
care worker's investment interest, the | ||||||
9 | same shall be disclosed; and
| ||||||
10 | (9) The entity shall establish an internal utilization | ||||||
11 | review program to
ensure that investing health care workers | ||||||
12 | provided appropriate or
necessary utilization; and
| ||||||
13 | (10) If a health care worker's financial interest in an | ||||||
14 | entity is
incompatible with a referred patient's
interest, | ||||||
15 | the health care worker shall make alternative arrangements | ||||||
16 | for
the patient's care.
| ||||||
17 | The Board shall make such a determination for a health care | ||||||
18 | worker within
90 days of a completed written request. Failure | ||||||
19 | to make such a
determination within the 90 day time frame shall | ||||||
20 | mean that no alternative
is practical based upon the facts set | ||||||
21 | forth in the completed written request.
| ||||||
22 | (c) It shall not be a violation of this Act for a health | ||||||
23 | care worker to
refer a patient for health services to a | ||||||
24 | publicly traded entity in which he or
she
has an investment | ||||||
25 | interest provided that:
| ||||||
26 | ( 1) the
entity is listed for trading on the New
York | ||||||
27 | Stock Exchange or on the American Stock Exchange, or is a | ||||||
28 | national
market system security traded under an automated | ||||||
29 | inter-dealer quotation
system operated by the National | ||||||
30 | Association of Securities Dealers; and
| ||||||
31 | (2) the entity had, at the end of the corporation's | ||||||
32 | most recent fiscal
year, total net assets of at least | ||||||
33 | $30,000,000
related to the furnishing of health services; | ||||||
34 | and
| ||||||
35 | (3) any investment interest obtained after the | ||||||
36 | effective date of this
Act is traded on the exchanges |
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1 | listed in paragraph 1 of subsection (c) of this Section
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2 | after the entity
became a publicly traded corporation; and
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3 | (4) the entity markets or furnishes its services to | ||||||
4 | referring
health care worker investors and other health | ||||||
5 | care workers on equal terms; and
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6 | (5) all stock held in such publicly traded companies, | ||||||
7 | including stock
held in the predecessor privately held | ||||||
8 | company, shall be of one class
without preferential | ||||||
9 | treatment as to status or remuneration; and
| ||||||
10 | (6) the entity does not loan funds or guarantee any | ||||||
11 | loans for health
care workers who are in a position to be | ||||||
12 | referred to an entity; and
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13 | (7) the income on the health care worker's investment | ||||||
14 | is tied to the
health care worker's equity in the entity | ||||||
15 | rather than to the volume of
referrals made; and
| ||||||
16 | (8) the investment interest does not exceed 1/2 of 1% | ||||||
17 | of the entity's total equity.
| ||||||
18 | (d) Any hospital licensed under the Hospital Licensing Act | ||||||
19 | shall not
discriminate against or otherwise penalize a health | ||||||
20 | care worker for
compliance with this Act.
| ||||||
21 | (e) Any health care worker or other entity shall not enter | ||||||
22 | into an
arrangement or scheme seeking to make referrals to | ||||||
23 | another health care
worker or entity based upon the condition | ||||||
24 | that the health care worker
or entity will make referrals with | ||||||
25 | an intent to evade the prohibitions of
this Act by inducing | ||||||
26 | patient referrals which would be prohibited by this Section
if | ||||||
27 | the health care worker or entity made the referral directly.
| ||||||
28 | (f) If compliance with the need and alternative investor | ||||||
29 | criteria is not
practical, the health care worker shall | ||||||
30 | identify to the patient reasonably
available alternative | ||||||
31 | facilities. The Board shall, by rule, designate when
compliance | ||||||
32 | is "not practical".
| ||||||
33 | (g) Health care workers may request from the Board that it | ||||||
34 | render an
advisory opinion that a referral to an existing or | ||||||
35 | proposed entity under
specified circumstances does or does not | ||||||
36 | violate the provisions of this
Act. The Board's opinion shall |
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1 | be presumptively correct. Failure to
render such an advisory | ||||||
2 | opinion within 90 days of a completed written
request pursuant | ||||||
3 | to this Section shall create a rebuttable presumption that a
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4 | referral described in the completed written request is not or | ||||||
5 | will not be a
violation of this Act.
| ||||||
6 | (h) Notwithstanding any provision of this Act to the | ||||||
7 | contrary, a health
care worker may refer
a patient, who is a | ||||||
8 | member of a health maintenance organization "HMO"
licensed in | ||||||
9 | this State, for health services to an entity, outside the
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10 | health care worker's office or group practice, in which the | ||||||
11 | health care
worker is an investor, provided that any such | ||||||
12 | referral is made pursuant to
a contract with the HMO.
| ||||||
13 | Furthermore, notwithstanding any provision of this Act to the | ||||||
14 | contrary, a
health care worker may refer an enrollee of a | ||||||
15 | "managed care community network",
as defined in subsection (b) | ||||||
16 | of Section 5-11 of the Illinois
Public
Aid Code, for health
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17 | services to an entity, outside the health care worker's office | ||||||
18 | or group
practice, in which the health care worker is an | ||||||
19 | investor, provided that any
such referral is made pursuant to a | ||||||
20 | contract with the managed care community
network.
| ||||||
21 | (Source: P.A. 92-370, eff. 8-15-01.)
| ||||||
22 | (225 ILCS 47/30 rep.)
| ||||||
23 | (225 ILCS 47/35 rep.)
| ||||||
24 | (225 ILCS 47/40 rep.)
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25 | Section 10. The Health Care Worker Self-Referral Act is | ||||||
26 | amended by repealing Sections 30, 35, and 40.
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27 | Section 99. Effective date. This Act takes effect on July | ||||||
28 | 1, 2004.
|