Opinion ID: 200100
Heading Depth: 3
Heading Rank: 1

Heading: The First Audit

Text: 44 Dr. Singh argues that the RAC's refusal to admit him to the Baystate Line and its recommendation that his Blue Cross patient panel be frozen were not in accordance with HCQIA standards. 12 With these contentions in mind, we review the record to determine whether a reasonable jury could determine that Dr. Singh overcame the statutory presumption that Blue Cross performed these professional review actions in accordance with the strictures of § 11112(a): 45 (1) in the reasonable belief that the action[s were] in the furtherance of quality health care, 46 (2) after a reasonable effort to obtain the facts of the matter, 47 (3) after adequate notice and hearing procedures [were] 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[s were] warranted by the facts known after such reasonable effort to obtain facts and after meeting the requirement of paragraph (3). 48 42 U.S.C. 11112(a). We follow the district court's thoughtful opinion and consider these two professional review actions in tandem because they both resulted from the first audit of Dr. Singh, conducted by Dr. Clayton. 49
50 The RAC decided to freeze Dr. Singh's patient panel and to deny him admission to the Baystate product line because of Dr. Clayton's audit. Dr. Singh claims that Blue Cross could not have reasonably believed that these actions would further quality health care and were warranted by the facts known. 51 First, Dr. Singh argues that, in some other cases where a health care entity was granted immunity, the health care entity only disciplined a physician in response to demonstrated harm to patients, or took less drastic measures than those recommended for Dr. Singh before opting to discipline the physician. See Gabaldoni v. Wash. Cty. Hosp. Ass'n, 250 F.3d 255, 261 (4th Cir.2001) (granting immunity where plaintiff physician had been subject to multiple lawsuits); Egan v. Athol Mem'l Hosp., 971 F.Supp. 37, 41, 44 (D.Mass. 1997) (granting immunity where defendants repeatedly received complaints from staff and plaintiff was required to complete courses); Mathews, 87 F.3d at 628, 629 (immunity granted where plaintiff physician injured patient with high speed drill). Dr. Singh essentially argues that the RAC could only have reasonably believed that professional review actions adverse to him would further quality health care if it was responding to documented patient injuries or if it prefaced its decisions to freeze his patient panel and deny him entry to the Baystate plan with other, less severe reeducation measures. 52 Neither position comports with the purpose of the HCQIA, or precedent interpreting it. The HCQIA was designed to prevent patient harm, not to assure an adequate response after it occurred. See 42 U.S.C. § 11101(1) (describing Congressional finding that peer review was necessary in order to keep incompetent physicians from harming patients). Therefore, Blue Cross was under no obligation to wait until a patient was actually harmed by Dr. Singh before it took preventive action limiting his access to Blue Cross customers and further investigating his practice. Blue Cross's failure to reeducate Dr. Singh also does not demonstrate that the RAC could not have reasonably... concluded that [its] actions would restrict incompetent behavior or would protect patients. H.R.Rep. No. 99-903 at 10, reprinted in 1986 U.S.C.C.A.N. 6384, 6392-93 (discussing the proper test to use in applying the first HCQIA standard). The RAC suspected that Singh could harm patients, and therefore restricted his access to them. Dr. Singh cites no authority for the proposition that Blue Cross was obliged to take the response least disruptive to Dr. Singh upon receiving evidence that his practices did not comply with the relevant standards of care. 53 Dr. Singh also argues that Blue Cross could not have reasonably believed that its professional review actions would further quality health care because Dr. Clayton's audit was not entirely critical. Dr. Clayton observed in his audit report that Singh appear[ed] to make a sincere effort to try to deal with ... multiple problems which are at the most challenging and at the very least many times difficult to attain satisfactory conclusions. However, Dr. Clayton also stated that Singh's documented treatment showed evidence of care somewhat below recognized standards of care. Dr. Clayton's praise for Dr. Singh's apparent good faith effort to help his patients does not so vitiate the negative aspects of his audit as to discredit Blue Cross's decision to base its adverse professional review actions on the Clayton audit. 54 Finally, Dr. Singh claims that Blue Cross took its professional review actions not because of quality of care issues, but because his practice was not cost efficient. He also notes that the first audit in part focused on over utilization of office visits and lab tests. Noting that almost all other HCQIA cases involved hospitals, providers of health care, Dr. Singh argues that it could reasonably be inferred that Blue Cross's primary concern was not to further quality health care, but to provide health care insurance to its members at a profit. 55 Dr. Singh offers a false dichotomy between furthering quality health care and overutilization of medical procedures and tests. If patients are being subjected to unnecessary procedures and tests, the consequences are both economic and medical. Dr. Singh offers no evidence that Blue Cross's RAC was acting only as a cost-cutting body when it reviewed his performance. The Clayton audit focused on health care concerns. Like the plaintiff physician who failed to overcome the statutory presumption of immunity in Mathews, Dr. Singh 56 has produced no evidence that [economic] considerations actually entered into the [RAC]'s decisionmaking process.... Rather, Dr. [Singh] appears to base his argument solely on his allegation that the defendants ... stood to gain by eliminating him.... 57 Mathews, 87 F.3d at 636. Although Dr. Clayton's audit did refer to a pattern of overutilization of medical resources in Dr. Singh's practices — including excessive and inappropriate lab tests, too-frequent office visits, and overly long treatment regimens of antibiotics — all of these criticisms are inextricably intertwined with medical concerns. No reasonable jury could conclude that the RAC's actions were not taken in the reasonable belief that its actions were warranted by the facts known from the Clayton audit to further quality health care. 58
59 For HCQIA immunity to attach to a professional review action, the decision must be taken after a reasonable effort to obtain the facts of the matter. 42 U.S.C. § 11112(a)(2). Dr. Singh's only challenge to the statutory presumption that Blue Cross acted in accordance with this standard while conducting the first audit is his assertion that the RAC focused on all of the patient files containing narcotic prescriptions even though Clayton's three-page report barely mentioned Singh's narcotic prescription practices. Even if we assume arguendo that the RAC did focus on patient files containing narcotic prescriptions, and was wrong to do so, those mistakes relate to the RAC's interpretation of the facts — not its effort to obtain the facts. Id. Blue Cross hired an independent auditor, Dr. Clayton, to conduct the first audit, which was based on twenty-five randomly selected patient files. The RAC carefully reviewed Clayton's report. Given these steps, no reasonable jury could find that Blue Cross failed to take its professional review action after a reasonable effort to obtain the facts of the matter. Id. c. Adequate Notice and Procedures 60 A professional review action must be taken 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. 42 U.S.C. § 11112(a)(3). The controlling question is whether the plaintiff has shown by a preponderance of the evidence, that the defendant[] did not provide him with fair and adequate process under the circumstances. Islami v. Covenant Med. Ctr. Inc., 822 F.Supp. 1361, 1377 (N.D.Iowa 1992). 61 Dr. Singh alleges that the first audit was not fair because Blue Cross did not select a mutually agreeable peer review consultant as required under the Audit Agreement. However, the record demonstrates that Dr. Singh was largely responsible for this state of affairs. The parties initially could not agree on a peer reviewer, with Dr. Singh refusing to accept any of the physicians nominated by Blue Cross. Although the physician nominated by Dr. Singh (Dr. Criss) worked at the same hospital as Dr. Singh, Blue Cross agreed to permit him to conduct the review. However, when that physician received the relevant paperwork, he decided not to conduct the review. After Dr. Singh failed to respond to Blue Cross's request that he nominate another physician, Blue Cross appointed Dr. Clayton to perform the review. Therefore, Dr. Singh was at least as responsible for the unfair appointment of Dr. Clayton as was Blue Cross. Dr. Singh cannot claim that Blue Cross's failure to appoint a mutually agreeable peer reviewer made the first audit unfair when his failure to cooperate with Blue Cross led to this result. 62 Dr. Singh also claims that Blue Cross should have permitted him to discuss Dr. Clayton's audit with Dr. Clayton before the RAC voted to deny Singh participation in the Baystate product line and to freeze Dr. Singh's patient panel. However, the HCQIA procedural standard does not require peer review bodies to guarantee the accused such a procedural safeguard. [N]othing in the Act requires that a physician be permitted to participate in the review of his care. Sklaroff v. Allegheny Health Educ. Found., No. CIV. A. 95-4758, 1996 WL 383137, at  (E.D.Pa. July 8, 1996); see also Smith, 31 F.3d at 1487 (stating that the HCQIA does not require peer review proceedings to look like regular trials in a court of law). Blue Cross's failure to permit Dr. Singh to discuss the first audit with Dr. Clayton, and its unilateral selection of Dr. Clayton as the peer reviewer after Singh's failure to assist in the selection of a mutually agreeable peer reviewer, did not so compromise the first audit as to permit a reasonable jury to find that Dr. Singh had overcome the statutory presumption that Blue Cross afforded adequate notice and fair procedures.