UNPUBLISHED

UNITED STATES COURT OF APPEALS

FOR THE FOURTH CIRCUIT

No. 12-2439

MARGO J. HEIN-MUNIZ, MD; PARKSIDE MEDICAL CONSULTANTS LLC, 

d/b/a Magnolia Medical,

Plaintiffs - Appellants,

v.

AIKEN REGIONAL MEDICAL CENTERS; UNIVERSAL HEALTH SERVICES, 

INC.; AIKEN OBSTETRICS & GYNECOLOGY ASSOCIATES PA; CARLOS A. 

MILANES; K. D. JUSTYN; OLETHA R. MINTO, MD; JAMES F. 

BOEHNER, MD; ROBERT D. BOONE, MD; JONATHAN H. ANDERSON, MD; 

THOMAS P. PAXTON, MD; UHS OF DELAWARE, INC.,

Defendants – Appellees.

Appeal from the United States District Court for the District of 

South Carolina, at Aiken. Joseph F. Anderson, Jr., District 

Judge. (1:10-cv-00986-JFA)

Submitted: June 14, 2013 Decided: July 5, 2013

Before NIEMEYER and AGEE, Circuit Judges, and HAMILTON, Senior 

Circuit Judge.

Affirmed by unpublished per curiam opinion.

Thornwell F. Sowell, III, David C. Dick, Alexis K. Lindsay, 

SOWELL GRAY STEPP & LAFFITTE, LLC, Columbia, South Carolina, for 

Appellants. Travis Dayhuff, NELSON MULLINS RILEY & SCARBOROUGH, 

LLP, Columbia, South Carolina, for Appellees.
2

Unpublished opinions are not binding precedent in this circuit.
3

PER CURIAM:

Margo J. Hein-Muniz, M.D. (“Muniz”),1 a physician whose 

clinical privileges at Aiken Regional Medical Center (“ARMC”) 

were terminated after a peer review proceeding, appeals the 

district court’s entry of summary judgment on the civil action 

she subsequently brought against the Appellees, in which she 

attacked the peer review process and the ultimate decision by 

ARMC’s Board of Governors (“Board”) to terminate her privileges. 

We affirm.

We forgo a full recounting of the facts, which are 

well known to the parties. The bulk of the parties’ arguments 

on appeal concern the applicability of the Health Care Quality 

Improvement Act (“HCQIA”), 42 U.S.C. § 11101-11152 (2006), which 

immunizes those who participate in a “professional review 

action” from monetary damages as long as the action is taken 

(1) in the reasonable belief that the action was in 

the furtherance of quality health care,

(2) after a reasonable effort to obtain the facts of 

the matter,

(3) after adequate notice and hearing procedures are 

afforded to the physician involved or after such 

other procedures as are fair to the physician 

under the circumstances, and

(4) in the reasonable belief that the action was 

warranted by the facts known after such 

 1 Muniz’s practice, Parkside Medical Consultants LLC, d/b/a 

Magnolia Medical, joins this appeal. For the sake of brevity, 

we refer to Appellants collectively as “Muniz.”
4

reasonable effort to obtain facts and after 

meeting the requirement of paragraph (3).

42 U.S.C. § 11112(a) (2006); Wahi v. Charleston Area Med. Ctr., 

Inc., 562 F.3d 599, 606-07 (4th Cir. 2009).

“A professional review action shall be presumed to 

have met the preceding standards necessary for [immunity] unless 

the presumption is rebutted by a preponderance of the evidence.” 

42 U.S.C. § 11112(a). In view of this presumption, whether the 

participants in the peer review action are entitled to summary 

judgment necessitates application of an “unconventional” 

standard: “whether a reasonable jury, viewing all facts in a 

light most favorable to [the plaintiff], could conclude that 

[she] had shown, by a preponderance of the evidence, that [the 

peer review participants’] actions fell outside the scope of 

section 11112(a).” Gabaldoni v. Wash. Cnty. Hosp. Ass’n, 250 

F.3d 255, 260 (4th Cir. 2001).

Having reviewed the record, we are persuaded that no

reasonable jury could have concluded that the Appellees failed 

to meet any of the four requirements of the HCQIA. First, no 

reasonable jury could have concluded that Muniz carried her 

burden of showing that the Board was not motivated by a 

reasonable belief that its termination of Muniz’s privileges was 

in the furtherance of quality health care — a goal that

certainly includes ensuring that physicians affiliated with ARMC 
5

are candid and truthful in their interactions with colleagues 

and patients. See, e.g., 42 U.S.C. § 11151(9) (2006); Singh v. 

Blue Cross/Blue Shield of Mass., Inc., 308 F.3d 25, 39 (1st Cir. 

2002). Because § 11112(a)(1) requires only a “reasonable 

belief” that the action was in furtherance of quality health 

care, the test is “an objective one which looks to the totality 

of the circumstances.” Imperial v. Suburban Hosp. Ass’n, Inc., 

37 F.3d 1026, 1030 (4th Cir. 1994); see also Gabaldoni, 250 F.3d 

at 261. 

Due to the objective nature of this court’s inquiry, 

“to the extent [Muniz’s] case relies on inferences of a 

conspiracy to oust [her], . . . such inferences do not create 

any genuine issues of fact . . . . In the HCQIA immunity 

context, the circuits that have considered the issue all agree 

that the subjective bias or bad faith motives of the peer 

reviewers is irrelevant.” Sugarbaker v. SSM Health Care, 190 

F.3d 905, 914 (8th Cir. 1999); see Cohlmia v. St. John Med. 

Ctr., 693 F.3d 1269, 1279 (10th Cir. 2012). And “[t]he fact 

that some of the specific concerns [identified by the hearing 

panel and the Medical Executive Committee] shifted or changed 

over time does not rebut the presumption that the hospital acted 

in the reasonable belief that it was furthering quality health 

care.” Lee v. Trinity Lutheran Hosp., 408 F.3d 1064, 1071 (8th 

Cir. 2005) (internal quotation marks omitted). Notwithstanding 
6

Muniz’s attempt to portray the Medical Executive Committee’s 

conduct as a conspiratorial ploy to eject her from ARMC, we can 

only conclude on the record that there was “enough evidence 

against [Muniz] for the Board to believe that it was furthering 

the quality of health care in terminating [her] privileges.” 

Gabaldoni, 250 F.3d at 261 (internal quotation marks omitted).

Given the extensive peer review process conducted in 

Muniz’s case, we likewise conclude that no reasonable jury could 

find that the Board had failed on the HCQIA’s second prong — to 

make a reasonable effort to obtain the pertinent facts. See 42 

U.S.C. § 11112(a)(2); Moore v. Williamsburg Reg’l Hosp., 560 

F.3d 166, 175-76 (4th Cir. 2009); Singh, 308 F.3d at 43; 

Gabaldoni, 250 F.3d at 261.

Muniz’s argument as to the third prong of § 11112(a) 

must meet the same fate. Even assuming that the safe harbor 

provisions found in 42 U.S.C. § 11112(b) (2006) apply only 

partially to the Board’s peer review action, but see, e.g.,

Moore, 560 F.3d at 176, we nonetheless think it inescapable that

the Board terminated Muniz’s privileges “after such other 

procedures as are fair to the physician under the 

circumstances.” 42 U.S.C. § 11112(a)(3). We do not believe 

that a reasonable jury could find that the procedural 

irregularities involving the hearing officer — unwise though 

some of them were — rendered Muniz’s peer review process unfair 
7

or objectively unreasonable. See Wahi, 562 F.3d at 610, 614 

(noting standard). Nor do we countenance Muniz’s assertion that 

she was insufficiently on notice that she was required to tell 

the truth during her peer review process and that her privileges 

could be terminated if she did not do so. A reasonable jury 

could only conclude that it was “fair” for the Board to 

terminate Muniz after giving her extensive opportunity in a 

lengthy hearing to explain her misrepresentations. 42 U.S.C. 

§ 11112(a)(3). See also Moore, 560 F.3d at 175 (“[T]he entire 

purpose of an immunity provision is to afford some discretionary 

latitude to decisionmakers to make close calls unhaunted by the 

specter of civil liability.”).

Finally, Muniz’s arguments as to the HCQIA’s fourth 

prong cannot forestall summary judgment, either, given that a 

reasonable jury could conclude only that the Board’s conduct was 

taken “in the reasonable belief that the action was warranted by 

the facts known” to it. 42 U.S.C. § 11112(a)(4). Because Muniz 

has failed to show that the facts relied upon by the Board were 

“so obviously mistaken or inadequate as to make reliance on them 

unreasonable,” she cannot defeat the presumption that the 

Board’s action complied with § 11112(a)(4). Meyers v. 

Columbia/HCA Healthcare Corp., 341 F.3d 461, 471 (6th Cir. 2003) 

(internal quotation marks omitted). See also Moore, 560 F.3d at 

172 (“HCQIA immunity allows hospitals to take prophylactic 
8

measures that need not involve proof of improper conduct beyond 

a reasonable doubt so long as statutory procedures designed to 

protect the reputation and livelihood of the physician have been 

observed.”). Nor does the HCQIA require the Board to consider 

less severe disciplinary options as long as the one chosen is 

reasonably warranted by the facts. Id. at 176; Singh, 308 F.3d 

at 38.

Because Muniz “has not met [her] burden of showing 

that the requirements in § 11112(a)(1)-(4) were not met” by the 

Board, the district court properly determined that the Appellees 

are immune from damages under the HCQIA. Moore, 560 F.3d at 

176.2 To the extent that any of Muniz’s substantive state law 

claims survive the operation of the HCQIA, we also conclude that 

the district court properly entered summary judgment on each of

them. See id. at 176-78.

Accordingly, we affirm the judgment of the district 

court. We dispense with oral argument because the facts and 

legal contentions are adequately presented in the material 

 2 Despite Muniz’s arguments that the district court abused 

its discretion in excluding certain expert testimony proferred 

by her and in declining to draw an adverse evidence on the basis 

of spoliated evidence, we disagree. See F.C. Wheat Mar. 

Corp. v. United States, 663 F.3d 714, 723 (4th Cir. 2011) 

(noting standard); Vulcan Materials Co. v. Massiah, 645 F.3d 

249, 260 (4th Cir. 2011) (same).
9

before this court and argument will not aid the decisional 

process.

AFFIRMED