PRIOR PRINTER'S NO. 2965 PRINTER'S NO. 3231
No. 2098 Session of 2007
INTRODUCED BY DeLUCA, BELFANTI, FRANKEL, HALUSKA, KOTIK, MOYER, SIPTROTH, WALKO, J. WHITE, WOJNAROSKI, PETRONE, YOUNGBLOOD AND GIBBONS, DECEMBER 6, 2007
AS REPORTED FROM COMMITTEE ON INSURANCE, HOUSE OF REPRESENTATIVES, AS AMENDED, FEBRUARY 12, 2008
AN ACT 1 Establishing a system for payment or reduction in payment for 2 preventable serious adverse events within Commonwealth 3 programs; informing health insurers of payment policies used 4 by Medicaid and Medicare; and providing for the powers and 5 duties of the Department of Public Welfare, the Insurance 6 Department, the Department of Health and the Department of 7 State. 8 The General Assembly of the Commonwealth of Pennsylvania 9 hereby enacts as follows: 10 Section 1. Short title. 11 This act shall be known and may be cited as the Preventable 12 Serious Adverse Events Act. 13 Section 2. Definitions. 14 The following words and phrases when used in this act shall 15 have the meanings given to them in this section unless the 16 context clearly indicates otherwise: 17 "Centers for Medicare and Medicaid Services" or "CMS." The 18 Centers for Medicare and Medicaid Services within the United 19 States Department of Health and Human Services.
1 "Department." The Insurance Department of the Commonwealth. 2 "Facility." A health care facility as defined in section 3 802.1 of the act of July 19, 1979 (P.L.130, No.48), known as the 4 Health Care Facilities Act, or an entity licensed as a hospital 5 under the act of June 13, 1967 (P.L.31, No.21), known as the 6 Public Welfare Code. 7 "Health care provider." A health care facility or a person, 8 including a corporation, university or other educational 9 institution licensed or approved by the Commonwealth to provide 10 health care or professional medical services as a physician, a 11 certified nurse midwife, a podiatrist, a certified registered 12 nurse practitioner, a physician assistant, a chiropractor, a 13 hospital, an ambulatory surgery center, a nursing home and a 14 birth center. 15 "Health payor." An individual or entity providing a group 16 health, sickness or accident policy, subscriber contract or 17 program issued or provided by an entity, including any one of 18 the following: 19 (1) The act of June 2, 1915 (P.L.736, No.338), known as 20 the Workers' Compensation Act. 21 (2) The act of May 17, 1921 (P.L.682, No.284), known as 22 The Insurance Company Law of 1921. 23 (3) The act of December 29, 1972 (P.L.1701, No.364), 24 known as the Health Maintenance Organization Act. 25 (4) The act of May 18, 1976 (P.L.123, No.54), known as 26 the Individual Accident and Sickness Insurance Minimum 27 Standards Act. 28 (5) 40 Pa.C.S. Ch. 61 (relating to hospital plan 29 corporations). 30 (6) 40 Pa.C.S. Ch. 63 (relating to professional health 20070H2098B3231 - 2 -
1 services plan corporations).
2 "Medical assistance." The Commonwealth's medical assistance
3 program established under the act of June 13, 1967 (P.L.31,
4 No.21), known as the Public Welfare Code.
5 "Preventable serious adverse event." A clearly defined
6 condition or negative consequence of care that results in
7 unintended injury or illness that could have been anticipated
8 and prepared for, but that occurs because of an error or other
9 system failure and results in a patient's death, loss of a body
10 part, disability or loss of bodily function lasting more than
11 seven days.
12 Section 3. Payment policy for preventable serious adverse
13 events.
14 (a) General rule.--The following criteria may SHALL be used <--
15 by health payors in determining when payment or partial payment
16 to a health care provider will be withheld:
17 (1) A preventable serious adverse event must occur.
18 (2) The preventable serious adverse event must be within
19 the control of the health care provider.
20 (3) The preventable serious adverse event must occur in
21 a health care facility.
22 (b) Language addressing payment policy.--Payments can only
23 be withheld by health payors for services related to a
24 preventable serious adverse event or care made necessary by the
25 preventable serious adverse event if the agreement or contract
26 between the health payor and health care provider contains
27 language addressing payment policy for preventable serious
28 adverse events.
29 (c) Restriction.--Health care providers shall not seek
30 payment directly from patients or the responsible party of the
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1 patient for preventable serious adverse events. 2 Section 4. Duties of Department of Public Welfare. 3 (a) Department responsibilities.--The Department of Public 4 Welfare is responsible for the following: 5 (1) Determining payment policy under medical assistance 6 with respect to reduced reimbursements to health care 7 providers for preventable serious adverse events. This 8 payment policy includes the criteria and clearly stated 9 payment policies affecting health care providers. 10 (2) Publishing the payment policy in the Pennsylvania 11 Bulletin following a 60-day 30-DAY public comment period. <-- 12 (b) Ongoing reviews.--Nothing in this section shall affect 13 ongoing reviews of medical assistance services conducted by the 14 Department of Public Welfare. 15 (C) HOSPITAL PAYMENT POLICY.--NOTHING IN THIS SECTION SHALL <-- 16 REQUIRE THE DEPARTMENT TO ALTER, AMEND OR REISSUE ANY PAYMENT 17 POLICY FOR INPATIENT HOSPITALS RELATING TO PREVENTABLE SERIOUS 18 ADVERSE EVENTS THAT WAS PROMULGATED PRIOR TO THE ENACTMENT OF 19 THIS ACT. 20 Section 5. Duties of Insurance Department. 21 The department shall annually notify health payors of the 22 list of preventable serious adverse events that CMS is using 23 under the Medicare program and that health payors shall be 24 permitted to withhold reimbursement under section 3. 25 Section 6. Duties of Department of Health. 26 The IN ACCORDANCE WITH THE ACT OF JULY 19, 1979 (P.L.130, <-- 27 NO.48), KNOWN AS THE HEALTH CARE FACILITIES ACT, THE Department 28 of Health shall be responsible for investigating patient 29 complaints regarding a health care facility that is seeking 30 payment directly from the patient for a preventable serious 20070H2098B3231 - 4 -
1 adverse event.
2 Section 7. Duties of Department of State.
3 The Department of State shall be responsible for
4 investigating patient complaints regarding a health care
5 provider that is not a health care facility that is seeking
6 payment directly from the patient for a preventable serious
7 adverse event.
8 Section 8 20. Effective date. <--
9 This act shall take effect in 180 days.
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