There have been a number of recent reports of Legionnaires’ disease being contracted in hospitals (most recently in Cleveland), including VA medical facilities. Most hospitals maintain safe conditions for their patients, but many times it is the hospital location that exposes the victim to legionnaires disease.
Important Distinction Between a Hospital Acquired Condition and a Community Acquired Condition
Hospital Acquired Legionnaires indicates that the patient contracted the disease while in the care of the hospital. Community Acquired Legionnaires would be where the patient contracted the disease outside of the hospital’s care. While a patient can contract legionnaires or basic pneumonia while in the hospital in the treatment, cases have been reported where the patient contracted the disease from a water fountain in the hospital.
Most family members are not focusing on the difference in the hospital’s designation of hospital or community acquired illnesses; however, hospitals routinely render these decisions for many reasons, including diagnosis, treatment, and prevention.
One of the unwritten reasons for making the distinction between the two is that it will determine whether the hospital can charge the health insurer or Medicare (CMS) for the charges incurred for the condition. If it is “Community Acquired” then the health insurance company will be responsible for the medical bills. However if the condition is found to have been “Hospital Acquired” then the hospital cannot bill the insurer or CMS, and the hospital is solely responsible for the resulting medical bills. The focus is on whether the condition was considered a Potentially Preventable Complication (PPC), or if it was a natural complication. The rules were enacted and updated through CMS, but most health insurance companies now comply with the same rules.
Present on Admission
The determination of whether a condition is considered a “Hospital Acquired Condition” (HAC) or a “Community Acquired Condition” (CAC) is made at the time of admission. The health care provider makes an overall assessment of the patient and renders a conclusion of what conditions are “Present on Admission” (POA). This determination is a significant decision since any condition that was not “Present on Admission” would be logically determined to be acquired while in the hospital and therefore be an HAC. In the event the patient’s condition of pneumonia or Legionnaires Disease is diagnosed on admission, or within a specified number of hours, then the condition is considered Community Acquired Pneumonia or Legionnaires.
Because of the latency period of Legionnaires Disease, the patient’s condition that is POA may not be the most accurate method of distinguishing between HAC and CAC. When faced with the determination of the location and date of acquiring the legionella, there can be much discretion by the health care provider. It is not to suggest that the health care provider as a practice will assign the condition as one of a Community Acquired Legionnaires, but where the health care provider is faced with the two options it would be understandable that the decision would favor a diagnosis of a community acquired condition rather than one acquired in the hospital.
Why This is Significant in Pursuing a Legionnaire’s Disease Claim
This also becomes an important issue if the victim is considering pursing a Legionnaire’s claim. In the event the victim believes that his exposure occurred in some hotel or in a pool, but the hospital concludes that it was acquired while in their care, the supposed defendant can use that information to defend the claim. In the more likely example, the victim knows that he was exposed while in the hospital, but the hospital seeks to charge CMS or the insurance company, or it begins damage control by attempting to show that the exposure was not acquired in the hospital. This type of recordation and conclusion may not be done with any involvement of the patient, and may show up later in the medical records or in the health insurance company records when the bills are submitted. It is important that proper discovery of this issue is done, a discussion with the treating physician is also scheduled, and that all medical and insurance records of the victim are obtained early in the process.