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20 ILCS 2215/4-2

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Powers and duties

The Department of Public Health must require all hospitals and ambulatory surgery centers to adopt a uniform system to submit patient claims and encounter data for payment from public and private payers.  This system must be adopted based on the adoption of a uniform electronic billing form required under HIPAA. 

The Department of Insurance must require all third party payers to accept the uniform billing form.  However, the third party payers may require additional information to determine benefit eligibility and reimbursement. 

Each licensed hospital must submit to the Department of Public Health inpatient and outpatient claims and encounter data for surgical and invasive procedures performed on each patient within 60 days of the end of each calendar quarter.  Ambulatory surgery centers are also required to do the same.  Claims and encounter data submitted must not include the patient’s social security number, but may include a unique patient identifier.  The Department must protect the confidentiality and privacy of patients through implementing regulations.  The regulations must also ensure that any patient identifying information is stored securely.  The claims and encounter data collected must be collected in accordance with HIPAA. 

The Department is also required to make available on its website a consumer guide and a hospital report card in order to educate and assist individuals in making health care decisions.  The Consumer Guide must include information on at least 30 inpatient conditions and procedures that the Department has identified as having the greatest variation in patient charges and quality of care.  The Consumer Guide must include up-to-date comparison information about each condition regarding volume of cases, average charges, risk adjusted mortality rates, and infection rates.  Mortality and infection rates must be based on information that hospitals and ambulatory surgery centers have submitted to the Department pursuant to this law or based on public health reporting laws.  Publicly disclosed information must be easy to understand and accessible.  The Consumer Guide must include information to enhance consumer decision-making, and may include voluntary accreditation by entities.  

Before the Department publicly discloses the information collected, the following process must be followed:

  • Hospitals, ambulatory surgery centers, and other stakeholders must be actively involved in developing the Department’s methodology for collecting, analyzing and disclosing information under this law;
  • The Department’s entire methodology is disclosed to all stakeholders and providers before information is disclosed publicly;
  • Data collection and analytical methodologies meet reliability and accuracy standards;
  • Limitations on collection and analytical methods used for providing comparative information are identified;
  • Comparative hospital and ambulatory surgery center information uses standard based norms;
  • Comparative hospital and ambulatory surgery center information is provided to those groups for review prior to disclosure, and allow those groups to make corrections or additions before publication;
  • Comparisons among hospitals and ambulatory surgery centers make adjustments for patient case mix and other relevant risk factors;
  • There are effective safeguards preventing the unauthorized use of hospital and ambulatory surgery center information;
  • There are effective safeguards to prevent against the dissemination of inaccurate, incomplete or invalid provider data;
  • There is regular evaluation of the quality and accuracy of hospital and ambulatory surgery center information that is reported;
  • Only the most basic form of identifying information for hospitals or ambulatory surgery centers is used.  Information of any sized hospital or ambulatory surgery center may be released, but must not identify specific employees or providers.  Patient identifiable information may not be released, and any input data must not be made a public record.

The Department must maintain a public outreach and education campaign to inform consumers about the Guide.  The Department must also take all necessary steps to ensure confidentiality of patient identifiable information.  The Department must also evaluate additional methods for comparing hospital performance, including the disclosure of NCQA measures.

Current as of June 2015