|
||||||||||||||||||||
|
||||||||||||||||||||
| ||||||||||||||||||||
| ||||||||||||||||||||
| ||||||||||||||||||||
1 | AN ACT concerning regulation.
| |||||||||||||||||||
2 | Be it enacted by the People of the State of Illinois, | |||||||||||||||||||
3 | represented in the General Assembly:
| |||||||||||||||||||
4 | Section 5. The Health Care Worker Self-Referral Act is | |||||||||||||||||||
5 | amended by changing Section 20 as follows:
| |||||||||||||||||||
6 | (225 ILCS 47/20)
| |||||||||||||||||||
7 | Sec. 20. Prohibited referrals and claims for payment.
| |||||||||||||||||||
8 | (a) A health care worker shall not refer a patient for | |||||||||||||||||||
9 | health services
to an entity outside the
the health care | |||||||||||||||||||
10 | worker's office or group practice in
which the health care | |||||||||||||||||||
11 | worker is an investor, unless the health care worker
directly | |||||||||||||||||||
12 | provides health services within the entity and will be | |||||||||||||||||||
13 | personally
involved with the provision of care to the referred | |||||||||||||||||||
14 | patient. | |||||||||||||||||||
15 | (b) Pursuant to Board determination that the following | |||||||||||||||||||
16 | exception is
applicable, a health care worker may invest in and | |||||||||||||||||||
17 | refer to an entity,
whether or not the health care worker | |||||||||||||||||||
18 | provides direct services within said
entity, if there is a | |||||||||||||||||||
19 | demonstrated need in the community for the entity and
| |||||||||||||||||||
20 | alternative financing is not available. For purposes of this | |||||||||||||||||||
21 | subsection
(b), "demonstrated need" in the community for the | |||||||||||||||||||
22 | entity may exist if (1)
there is no facility of reasonable | |||||||||||||||||||
23 | quality that provides medically
appropriate service, (2) use of |
| |||||||
| |||||||
1 | existing facilities is onerous or creates
too great a hardship | ||||||
2 | for patients,
(3) the entity is formed to own or lease medical | ||||||
3 | equipment which replaces
obsolete or otherwise inadequate | ||||||
4 | equipment in or under the control of a
hospital located in a | ||||||
5 | federally designated health manpower shortage area,
or (4) such | ||||||
6 | other standards as
established, by rule, by the Board. | ||||||
7 | "Community" shall be defined as a
metropolitan area for a city, | ||||||
8 | and a county for a rural area. In addition,
the following | ||||||
9 | provisions must be met to be exempt under this Section:
| ||||||
10 | (1) Individuals who are not in a position to refer | ||||||
11 | patients to an
entity are given a bona fide opportunity to | ||||||
12 | also invest in the entity on the
same terms as those | ||||||
13 | offered a referring health care worker; and
| ||||||
14 | (2) No health care worker who invests shall be required | ||||||
15 | or encouraged
to make referrals to the entity or otherwise
| ||||||
16 | generate business as a condition of becoming or remaining | ||||||
17 | an investor; and
| ||||||
18 | (3) The entity shall market or furnish its services to
| ||||||
19 | referring health care worker investors and other investors | ||||||
20 | on equal terms; and
| ||||||
21 | (4) The entity shall not loan funds or guarantee any | ||||||
22 | loans for health
care workers who are in a position to | ||||||
23 | refer to an entity; and
| ||||||
24 | (5) The income on the health care worker's investment | ||||||
25 | shall be tied to
the health care worker's equity in the | ||||||
26 | facility rather than to the volume
of referrals made; and
|
| |||||||
| |||||||
1 | (6) Any investment contract between the entity and the | ||||||
2 | health care
worker shall not include any covenant or | ||||||
3 | non-competition clause that
prevents a health care worker | ||||||
4 | from investing in other entities; and
| ||||||
5 | (7) When making a referral, a health care worker must | ||||||
6 | disclose his
investment interest in an entity to the | ||||||
7 | patient being referred to such
entity. If alternative | ||||||
8 | facilities are reasonably available, the health care
| ||||||
9 | worker must provide the patient with a list of alternative | ||||||
10 | facilities.
The health care worker shall inform the patient | ||||||
11 | that they have the option to use
an alternative facility | ||||||
12 | other than one in which the health care worker has
an | ||||||
13 | investment interest and the patient will not be treated | ||||||
14 | differently by
the health care worker if the patient | ||||||
15 | chooses to use another entity.
This shall be applicable to | ||||||
16 | all health care worker investors, including
those who | ||||||
17 | provide direct care or services for their patients in | ||||||
18 | entities
outside their office practices; and
| ||||||
19 | (8) If a third party payor requests information with | ||||||
20 | regard to a health
care worker's investment interest, the | ||||||
21 | same shall be disclosed; and
| ||||||
22 | (9) The entity shall establish an internal utilization | ||||||
23 | review program to
ensure that investing health care workers | ||||||
24 | provided appropriate or
necessary utilization; and
| ||||||
25 | (10) If a health care worker's financial interest in an | ||||||
26 | entity is
incompatible with a referred patient's
interest, |
| |||||||
| |||||||
1 | the health care worker shall make alternative arrangements | ||||||
2 | for
the patient's care.
| ||||||
3 | The Board shall make such a determination for a health care | ||||||
4 | worker within
90 days of a completed written request. Failure | ||||||
5 | to make such a
determination within the 90 day time frame shall | ||||||
6 | mean that no alternative
is practical based upon the facts set | ||||||
7 | forth in the completed written request.
| ||||||
8 | (c) It shall not be a violation of this Act for a health | ||||||
9 | care worker to
refer a patient for health services to a | ||||||
10 | publicly traded entity in which he or
she
has an investment | ||||||
11 | interest provided that:
| ||||||
12 | (1) the
entity is listed for trading on the New
York | ||||||
13 | Stock Exchange or on the American Stock Exchange, or is a | ||||||
14 | national
market system security traded under an automated | ||||||
15 | inter-dealer quotation
system operated by the National | ||||||
16 | Association of Securities Dealers; and
| ||||||
17 | (2) the entity had, at the end of the corporation's | ||||||
18 | most recent fiscal
year, total net assets of at least | ||||||
19 | $30,000,000
related to the furnishing of health services; | ||||||
20 | and
| ||||||
21 | (3) any investment interest obtained after the | ||||||
22 | effective date of this
Act is traded on the exchanges | ||||||
23 | listed in paragraph 1 of subsection (c) of this Section
| ||||||
24 | after the entity
became a publicly traded corporation; and
| ||||||
25 | (4) the entity markets or furnishes its services to | ||||||
26 | referring
health care worker investors and other health |
| |||||||
| |||||||
1 | care workers on equal terms; and
| ||||||
2 | (5) all stock held in such publicly traded companies, | ||||||
3 | including stock
held in the predecessor privately held | ||||||
4 | company, shall be of one class
without preferential | ||||||
5 | treatment as to status or remuneration; and
| ||||||
6 | (6) the entity does not loan funds or guarantee any | ||||||
7 | loans for health
care workers who are in a position to be | ||||||
8 | referred to an entity; and
| ||||||
9 | (7) the income on the health care worker's investment | ||||||
10 | is tied to the
health care worker's equity in the entity | ||||||
11 | rather than to the volume of
referrals made; and
| ||||||
12 | (8) the investment interest does not exceed 1/2 of 1% | ||||||
13 | of the entity's total equity.
| ||||||
14 | (d) Any hospital licensed under the Hospital Licensing Act | ||||||
15 | shall not
discriminate against or otherwise penalize a health | ||||||
16 | care worker for
compliance with this Act.
| ||||||
17 | (e) Any health care worker or other entity shall not enter | ||||||
18 | into an
arrangement or scheme seeking to make referrals to | ||||||
19 | another health care
worker or entity based upon the condition | ||||||
20 | that the health care worker
or entity will make referrals with | ||||||
21 | an intent to evade the prohibitions of
this Act by inducing | ||||||
22 | patient referrals which would be prohibited by this Section
if | ||||||
23 | the health care worker or entity made the referral directly.
| ||||||
24 | (f) If compliance with the need and alternative investor | ||||||
25 | criteria is not
practical, the health care worker shall | ||||||
26 | identify to the patient reasonably
available alternative |
| |||||||
| |||||||
1 | facilities. The Board shall, by rule, designate when
compliance | ||||||
2 | is "not practical".
| ||||||
3 | (g) Health care workers may request from the Board that it | ||||||
4 | render an
advisory opinion that a referral to an existing or | ||||||
5 | proposed entity under
specified circumstances does or does not | ||||||
6 | violate the provisions of this
Act. The Board's opinion shall | ||||||
7 | be presumptively correct. Failure to
render such an advisory | ||||||
8 | opinion within 90 days of a completed written
request pursuant | ||||||
9 | to this Section shall create a rebuttable presumption that a
| ||||||
10 | referral described in the completed written request is not or | ||||||
11 | will not be a
violation of this Act.
| ||||||
12 | (h) Notwithstanding any provision of this Act to the | ||||||
13 | contrary, a health
care worker may refer
a patient, who is a | ||||||
14 | member of a health maintenance organization "HMO"
licensed in | ||||||
15 | this State, for health services to an entity, outside the
| ||||||
16 | health care worker's office or group practice, in which the | ||||||
17 | health care
worker is an investor, provided that any such | ||||||
18 | referral is made pursuant to
a contract with the HMO.
| ||||||
19 | Furthermore, notwithstanding any provision of this Act to the | ||||||
20 | contrary, a
health care worker may refer an enrollee of a | ||||||
21 | "managed care community network",
as defined in subsection (b) | ||||||
22 | of Section 5-11 of the Illinois
Public
Aid Code, for health
| ||||||
23 | services to an entity, outside the health care worker's office | ||||||
24 | or group
practice, in which the health care worker is an | ||||||
25 | investor, provided that any
such referral is made pursuant to a | ||||||
26 | contract with the managed care community
network.
|
| |||||||
| |||||||
1 | (Source: P.A. 92-370, eff. 8-15-01.)
|