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

Heading: The Second Audit

Text: 63 Dr. Singh argues that the RAC's recommendation that Blue Cross remove him from its panel of providers was unreasonable and based on a shoddy investigation. We again review the record to determine whether Dr. Singh has demonstrated that a reasonable jury could find that he overcame the statutory presumption that Blue Cross performed this professional review action in accordance with the strictures of § 11112(a). 64
65 We first consider whether Dr. Singh has rebutted the presumption that the RAC recommended his termination in the reasonable belief that the action was in the furtherance of quality health care and in the reasonable belief that the action was warranted by the facts known. 42 U.S.C. § 11112(a)(1) and (4). To overcome the presumption, Dr. Singh must demonstrate that a reasonable jury could find that Blue Cross could not have concluded that [its] action would restrict incompetent behavior or would protect patients. Egan, 971 F.Supp. at 42 (internal quotation marks omitted); accord Bryan, 33 F.3d at 1334-35. As explained herein, he fails to meet this burden. 66 Dr. Singh argues that the Fair Hearing Panel's ultimate decision to reverse the RAC's recommendation of his termination would permit a reasonable jury to find that the RAC could not have terminated him with a reasonable belief that this action would further quality health care. We disagree. The reversal of a peer review committee's recommendation of an adverse professional review action by a higher level peer review panel does not indicate that the initial recommendation was made without a reasonable belief that the recommendation would further quality health care. Austin, 979 F.2d at 735 (granting immunity even where a Judicial Review Committee reversed a Medical Executive Committee's recommendation of adverse professional review action). The Fair Hearing Panel had more information before it when it reviewed Dr. Singh's case than the RAC did. The appropriate inquiry is whether the decision was reasonable in light of the facts known at the time the decision was made, not in light of facts later discovered. Sklaroff, 1996 WL 383137 at . Although the Fair Hearing Panel's ultimate disposition of the case suggests that the RAC erred, it does not resolve the question whether the RAC had reasonable grounds to believe that its decision would further quality health care. See Imperial, 37 F.3d at 1030 ([T]he Act does not require that the professional review result in an actual improvement of the quality of health care. Rather, the defendants' action is immune if the process was undertaken in the reasonable belief that quality health care was being furthered.). 67 When the RAC reviewed Dr. Singh's case, the primary source of information before it was Dr. White's audit, which extensively criticized Dr. Singh. Dr. White reported substandard care in thirty-three of the thirty-seven files he reviewed. As in Gabaldoni, the record is replete with objective evidence of [Dr. Singh's] deviations from ... the applicable standard of care; [Blue Cross] reasonably relied on ... such evidence in support of its professional review action. 250 F.3d at 261. Although Dr. Singh alleges several procedural irregularities in Dr. White's audit, he does not directly challenge Dr. White's conclusions in any particular case. 14 Moreover, Dr. Singh offers no reason why the RAC should have doubted the accuracy of Dr. White's assessment in any particular case. 68 Dr. White's report questioned Dr. Singh's care of patients with chronic back and neck pain ..., patients with emotional disorders ..., and asthma patients. Singh v. Blue Cross & Blue Shield of Mass., Inc., 182 F.Supp.2d 164, 174 (D.Mass.2001). Dr. White concluded that [t]here is a general pattern of inadequate or delayed evaluation and treatment, and failure to refer. Competent [expert] care is rarely seen. Id. (citation omitted). Furthermore, the physician members of the RAC did not just take Dr. White's report on faith — they also reviewed several of the patient records upon which it was based prior to the vote. Thus, Dr. Singh has not demonstrated that a reasonable jury could find that he rebutted the statutory presumption that the RAC took its professional review action in the reasonable belief that its action was in furtherance of quality health care and was warranted by the facts known. 42 U.S.C. § 11112(a)(4). 15 69
70 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 claims that Blue Cross used an unreasonably narrow procedure in obtaining the facts it relied upon in deciding his case. He asserts that this case is analogous to Brown, where the court determined that a reasonable jury could have found that the hospital's peer review action was not taken after a reasonable effort to obtain the facts of the matter because a witness testified that a peer review panel's reliance on only two charts prior to revoking a doctor's privileges was unreasonably narrow and did not provide a reasonable basis for concluding Dr. Brown posed a threat to patient safety. 101 F.3d at 1334. Dr. Singh argues that his review was as unreasonably narrow as Dr. Brown's, at least with respect to the type of cases used, since, [o]f the total of thirty-seven patient files submitted to Dr. White, 21(57%) contained narcotic prescriptions. 71 Dr. Singh misconstrues Brown. There, the court criticized the review as narrow because of the small sample of cases it contained, not because the sample focused on one particular type of case. Courts have found that peer reviewers made a reasonable effort to obtain the facts of the matter even when they concentrated on areas of special concern. See Smith, 31 F.3d at 1483 (review committees focused on problem cases of the plaintiff doctor); Bryan, 33 F.3d at 1326-28 (review panels focused on incidents in which mercurial doctor abused hospital staff). Health care entities are entitled to focus on certain types of cases when these types of cases have caused concern. Moreover, Dr. Singh concedes that sixteen of the patient files submitted to Dr. White did not contain narcotic prescriptions. Thus, Dr. White and the RAC reviewed at least eight times as many randomly selected cases as Presbyterian Hospital's peer reviewer did in Brown. 16 72 In a further challenge to Dr. White's audit, Dr. Singh asserts that [t]he RAC: (1) erroneously reviewed the files of at least two (2) patients who were not treated by Dr. Singh; (2) selected a nonrandom sample of patient files showing exaggerated narcotic prescriptions practices. However, Dr. Singh does not explain why the inclusion of these two files in Dr. White's review invalidated the conclusions drawn from the review of the numerous files that were indisputably his. As we have discussed above, Blue Cross was entitled to review a nonrandom sample of Dr. Singh's files. See Smith, 31 F.3d at 1483; Bryan, 33 F.3d at 1326-28. Admittedly, Blue Cross should have told the peer reviewer, Dr. White, that the sample was weighted toward cases involving narcotics prescriptions. However, this oversight was not material to Dr. White's findings. 73 Dr. White did not simply give a global evaluation of the cases he reviewed. Rather, he analyzed each case individually and concluded, in nearly all cases, that Dr. Singh provided substandard care. For example, Dr. White observed in one case that 74 [c]hronic back pain is treated with narcotic analgesics (Darvon and Percocet) in addition to Lodine. Most internists would have tried to avoid the narcotic analgesics, which were prescribed in significant quantities over the year. In a similar case, Dr. White observed: 75 [L]ow back pain is treated with narcotic analgesics (Percocet) in addition to Motrin. Most internists would have tried to limit analgesic therapy to Motrin and other [nonprescription drugs]. 76 Dr. White's twenty pages of notes on individual patients and five-page letter explaining his conclusions criticized Dr. Singh for far more than his narcotics prescription practices; they touched on many other areas of concern. Dr. White criticized Dr. Singh's care of patients with chronic back and neck pain as significantly `sub-standard,' stated that Dr. Singh failed to meet the minimal standards of the medical community in his treatment of patients with emotional disorders, and failed to deliver quality care to asthma patients. Dr. White concluded that [t]here is a general pattern of inadequate or delayed evaluation and treatment, and failure to refer. Competent expert care is rarely seen. 77 The relevant inquiry under § 11112(a)(2) is whether the totality of the process leading up to the [RAC]'s `professional review action' [recommending that Blue Cross terminate Dr. Singh's participation] evidenced a reasonable effort to obtain the facts of the matter. Mathews, 87 F.3d at 637. Prior to the termination vote, Blue Cross had conducted two audits of Dr. Singh's practice (by two independent physicians), and the five physician members of the RAC had reviewed the audit reports and many underlying patient records. Although Blue Cross made some mistakes in forwarding the files to Dr. White for his review, the [p]laintiff is entitled to a reasonable investigation under the Act, not a perfect investigation. Egan, 971 F.Supp. at 43 (citing 42 U.S.C. § 11112(a)(2)) (internal quotation marks omitted). Given the two audits and the level of attention Dr. White gave to each chart he reviewed, no reasonable jury could find that Dr. Singh overcame the statutory presumption that Blue Cross engaged in a reasonable effort to obtain relevant facts. 78
79 Dr. Singh only presents one argument that the second audit did not afford him fair process, faulting Blue Cross for failing to give him an opportunity to discuss with Dr. White the results of the second audit. However, again, nothing in the [HCQIA] requires that a physician be permitted to participate in the review of his care. Sklaroff, 1996 WL 383137 at ; see also Smith, 31 F.3d at 1487 (explaining that the HCQIA does not require peer review proceedings to look like regular trials in a court of law). Moreover, Blue Cross gave Dr. Singh the opportunity to challenge the White audit at the Fair Hearing Panel. Dr. Singh successfully challenged it there. Under these circumstances, no reasonable jury could find that Dr. Singh overcame the statutory presumption that Blue Cross provided him with procedures that were fair.