Full Text of HB5636 95th General Assembly
HB5636 95TH GENERAL ASSEMBLY
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95TH GENERAL ASSEMBLY
State of Illinois
2007 and 2008 HB5636
Introduced , by Rep. Elizabeth Coulson SYNOPSIS AS INTRODUCED: |
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Amends the Health Care Worker Self-Referral Act. Makes a technical change in
a
Section concerning prohibited referrals and claims for payment.
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A BILL FOR
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HB5636 |
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LRB095 16595 RAS 42626 b |
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| AN ACT concerning regulation.
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| Be it enacted by the People of the State of Illinois, | 3 |
| represented in the General Assembly:
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| Section 5. The Health Care Worker Self-Referral Act is | 5 |
| amended by changing Section 20 as follows:
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| (225 ILCS 47/20)
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| Sec. 20. Prohibited referrals and claims for payment.
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| (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
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| 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 |
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LRB095 16595 RAS 42626 b |
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| 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:
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| (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
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| (2) No health care worker who invests shall be required | 15 |
| or encouraged
to make referrals to the entity or otherwise
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| generate business as a condition of becoming or remaining | 17 |
| an investor; and
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| (3) The entity shall market or furnish its services to
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| referring health care worker investors and other investors | 20 |
| on equal terms; and
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| (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
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| (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
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LRB095 16595 RAS 42626 b |
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| (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
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| (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
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| 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
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| (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
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| (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
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| (10) If a health care worker's financial interest in an | 26 |
| entity is
incompatible with a referred patient's
interest, |
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| the health care worker shall make alternative arrangements | 2 |
| for
the patient's care.
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| 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.
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| (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:
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| (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
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| (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
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| (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
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| after the entity
became a publicly traded corporation; and
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| (4) the entity markets or furnishes its services to | 26 |
| referring
health care worker investors and other health |
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| care workers on equal terms; and
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| (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
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| (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
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| (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
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| (8) the investment interest does not exceed 1/2 of 1% | 13 |
| of the entity's total equity.
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| (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.
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| (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.
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| (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 |
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| facilities. The Board shall, by rule, designate when
compliance | 2 |
| is "not practical".
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| (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
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| referral described in the completed written request is not or | 11 |
| will not be a
violation of this Act.
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| (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
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| 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.
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| 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
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| 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.
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| (Source: P.A. 92-370, eff. 8-15-01.)
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