Opinion ID: 200100
Heading Depth: 2
Heading Rank: 3

Heading: The Professional Review Actions Challenged By Dr. Singh

Text: 35 There are many elements of a peer review, including investigation, deliberation, recommended actions and final decisions. The HCQIA addresses professional review actions. A professional review action is defined in the HCQIA as: 36 an action or recommendation of a professional review body which is taken or made in the conduct of professional review activity, which is based on the competence or professional conduct of an individual physician (which conduct affects or could affect adversely the health or welfare of a patient or patients), and which affects (or may affect) adversely the clinical privileges, or membership in a professional society, of the physician. Such term includes a formal decision of a professional review body not to take an action or make a recommendation described in the previous sentence and also includes professional review activities relating to a professional review action. 37 42 U.S.C. § 11151(9). Professional review activities are generally precursors to professional review actions. Professional review activities include a health care entity's efforts 38 (A) to determine whether the physician may have clinical privileges with respect to, or membership in, the entity, 39 (B) to determine the scope or conditions of such privileges or membership, or 40 (C) to change or modify such privileges or membership. 41 42 U.S.C. § 11151(10). When a court considers whether a health care entity is immune from damages for a given professional review action, it considers whether that action, considered as a whole, and including all the professional review activities relating to it, meets the standards set forth in § 11112(a). 42 The district court determined that Blue Cross took three professional review actions with respect to Dr. Singh. As a result of the first audit, Blue Cross (1) decided not to permit Dr. Singh to become a provider for the Baystate Line, and (2) decided to freeze his HMO Blue patient panel. As a result of the second audit, Blue Cross (3) terminated Dr. Singh as a Blue Cross provider. 11