Opinion ID: 1028445
Heading Depth: 3
Heading Rank: 1

Heading: HCQIA Immunity

Text: Wahi asserts the district court erred in determining CAMC was entitled to immunity under the HCQIA because CAMC never held a hearing regarding Wahi's suspension, and therefore did not satisfy the requirements for claiming immunity under the Act. (Br. Appellant 18-30; Reply Br. 2-15.) However, we conclude the district court did not err in determining CAMC was entitled to immunity under the particular facts of this case. The HCQIA provides a professional review body [15] with immunity from damages whenever a professional review action [16] 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 reasonable effort to obtain facts and after meeting the requirement of paragraph (3). 42 U.S.C.A. § 11112(a) (West 2005). 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. Id. Due to the presumption of immunity under the HCQIA, a court applies an unconventional standard in determining whether summary judgment is appropriatewhether a reasonable jury, viewing all facts in a light most favorable to [Wahi], could conclude that he had shown, by a preponderance of the evidence, that [CAMC's] actions fell outside the scope of section 11112(a). Gabaldoni v. Washington County Hosp. Ass'n, 250 F.3d 255, 260 (4th Cir.2001). In determining whether a health care entity has met these four requirements, the Court applies an objective test that looks to the totality of the circumstances to determine whether the action satisfies the § 11112(a) provisions. Imperial v. Suburban Hosp. Ass'n, 37 F.3d 1026, 1030 (4th Cir.1994). In a footnote in his opening brief, Wahi contends that even though the primary focus of this appeal is the failure of CAMC to schedule a hearing, as required under subsection 3 of § 11112(a), the first, second and fourth prongs of the test [for immunity under the HCQIA] were also not met. (Br. Appellant 29 n. 11.) Other than this declarative sentence, Wahi fails to raise any argument to support his claim that the first, second, and fourth prongs of the subsection (a) immunity criteria were not met. [17] Federal Rule of Appellate Procedure 28(a)(9)(A) requires that the argument section of an appellant's opening brief must contain the appellant's contentions and the reasons for them, with citations to the authorities and parts of the record on which the appellant relies. Because Wahi has failed to comply with the specific dictates of Rule 28(a)(9)(A), we conclude that he has waived his claims as to the first, second, and fourth requirements of the subsection (a) HCQIA immunity test on appeal. See 11126 Baltimore Boulevard, Inc., 58 F.3d at 993 n. 7 (involving predecessor to Federal Rule of Appellate Procedure 28(a)(9)(A)). Accordingly, our review regarding the immunity issue is limited to whether the district court erred in determining that Wahi did not overcome the presumption that CAMC satisfied the requirements of subsection (a)(3). A health care entity is deemed to have met the adequate notice and hearing requirement of § 11112(a)(3) when it satisfies the safe harbor provisions of § 11112(b). Wahi argues that because CAMC failed to follow the provisions of subsection (b), it does not qualify for immunity under the HCQIA. However, as the district court properly recognized, (J.A. 275), following the provisions of subsection (b) is but one way a health care entity can comply with the requirements of subsection (a)(3). While a health care entity is deemed to have met the subsection (a)(3) immunity requirements by following the safe harbor provisions of subsection (b), those provisions are not exclusive. [F]ailure to meet the conditions described [in subsection (b)] shall not, in itself, constitute failure to meet the standards of subsection (a)(3). § 11112(b)(3). Therefore, Wahi's argument that CAMC is not entitled to immunity, as a matter of law, because it did not comply with all of the provisions in subsection (b), fails under the plain language of the statute. Wahi next asserts that CAMC is not entitled to immunity because it failed to satisfy the exceptions from immunity carved out in § 11112(c). Wahi contends that since CAMC summarily suspended him for more than 14 days without first finding that he posed an imminent danger to his patients and without conducting a post-suspension investigation, CAMC cannot claim immunity under the HCQIA. Wahi misreads the statute. Subsection (c) sets forth limited circumstances in which a health care entity can act with immunity without satisfying all of the conditions in subsection (a). Subsection (c) provides in pertinent part: For purposes of section 11111(a) of this title, nothing in this section shall be construed as (1) requiring the procedures referred to in subsection (a)(3) of this section (A) where there is no adverse professional review action taken, or (B) in the case of a suspension or restriction of clinical privileges, for a period of not longer than 14 days, during which an investigation is being conducted to determine the need for a professional review action; or (2) precluding an immediate suspension or restriction of clinical privileges, subject to subsequent notice and hearing or other adequate procedures, where the failure to take such an action may result in an imminent danger to the health of any individual. § 11112(c). Subsection (c) thus sets out distinct ways in which a health care entity can be immune under the HCQIA without having complied with the usual requirements for claiming immunity. Wahi would have us read the statute by ignoring this clear purpose and instead find that the HCQIA immunity is barred by failing to meet one of the subsection (c) prongs. To the contrary, subsection (c) presents additional routes to HCQIA immunity beyond that set forth in subsection (a)(3). Although Wahi may be correct that the facts show CAMC cannot assert immunity based on (c)(1) or (c)(2), the only significance is that CAMC must meet the usual standard of qualifying for immunity set forth in subsection (a)(3). [18] Under subsection (a)(3), a health care entity seeking HCQIA immunity must act 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. § 11112(a)(3) (emphasis added). Stated in the disjunctive, the statute contemplates two independent avenues by which the subsection (a) immunity prong may be obtained. The first avenue, adequate notice and hearing procedures, is not at issue in the case at bar. CAMC makes no claim under that prong and the district court did not consider it. What CAMC argues, and the district court held, is that the unique circumstances in this case show that Wahi received other procedures as are fair to the physician under the circumstances, and entitle CAMC to the HCQIA immunity. Wahi cites the legislative history of subsection (a)(3) to assert that the other procedures undertaken by a health care entity must nonetheless include a hearing. In particular, Wahi relies on this language from the 1986 House Report recommending the adoption of the HCQIA: The due process requirement [i.e., subsection (a)(3),] can always be met by the procedures specified in subsection (b).... If other procedures are followed, but are not precisely of the character spelled out in [subsection (b)], the test of adequacy may still be met under other prevailing law. The Committee is aware, for example, that some courts have already carefully spelled out different requirements for certain professional review activities or actions, such as procedures for decisions regarding applicants for clinical privileges at a hospital. In those situations, compliance with applicable law should satisfy the adequacy requirement even where such activities or actions require different or fewer due process rights than the ones specified under [subsection (b)]. In any case, it is the Committee's intent that physicians receive fair and unbiased review to protect their reputations and medical practices. H.R.Rep. No. 99-903, at 10-11 (1986), as reprinted in 1986 U.S.C.C.A.N. 6384, 6393. Nothing in this legislative history alters the conclusion that a health care entity can satisfy subsection (a)(3) without providing a formal hearing, as contemplated in the safe harbor provisions, depending on the circumstances of a particular case. Rather, Congress' intentand that expressed by the plain language of the statuteis that a physician be afforded adequate and fair procedures with regard to professional review actions, which could be something other than a formal hearing in some circumstances. If this were not so, Congress would have no reason to have included the other procedures appropriate ... under the circumstances language contained in the statute in contrast to the specific notice and hearing language. Wahi also contends that CAMC's failure to follow some of the procedures outlined in its Bylaws and Procedures Manual proves CAMC did not satisfy subsection (a)(3) under the alternative prong. However, as the Court of Appeals for the Fifth Circuit recently observed, HCQIA immunity is not coextensive with compliance with an individual hospital's bylaws. Rather, the statute imposes a uniform set of national standards. Provided that a peer review action ... complies with those standards, a failure to comply with hospital bylaws does not defeat a peer reviewer's right to HCQIA immunity from damages. Poliner v. Tex. Health Sys., 537 F.3d 368, 380-81 (5th Cir.2008); see also Meyers v. Columbia/HCA Healthcare Corp., 341 F.3d 461, 469-71 (6th Cir.2003). Nothing in the subsection (a)(3) phrase such other procedures as are fair ... under the circumstances mandates by-law compliance as the sine qua non for immunity, although from a practical standpoint, by-law compliance may often be proof of such procedures in many cases. Having concluded that CAMC was not required to hold a formal hearing as a mandatory condition precedent to satisfying subsection (a)(3), we now examine whether the district court properly determined CAMC provided Wahi with such other procedures as are fair ... under the circumstances. We begin that review by underscoring the unique procedural posture upon which summary judgment for a health care entity is measured under the HCQIA, as the district court properly summarized: In applying the test outlined in § 11112(a), we begin with the presumption that the hospital has met the necessary standards for immunity unless this presumption is rebutted by a preponderance of the evidence. § 11112(a). The applicable standard is one of objective reasonableness, viewed in light of the totality of the circumstances. Freilich[ v. Upper Chesapeake Health, Inc., 313 F.3d 205,] 212 [(4th Cir.2002)] (quoting Imperial v. Suburban [Hosp. Ass'n], 37 F.3d 1026, 1030 (4th Cir. 1994)). Reasonableness standards have been consistently upheld in the context of qualified immunity. Freilich, 313 F.3d at 213. Wahi, 453 F.Supp.2d at 950. (J.A. 270.) We find no error in the district court's determination that Wahi failed to rebut the presumption that CAMC's actions satisfied the statutory requirement when the totality of the circumstances are viewed in an objectively reasonable manner. [REDACTED] informed Wahi of the allegations from the Credentials Committee by letter dated July 16 and further discussed them in a meeting with him on July 17. (J.A. 575-77.) Moreover, Wahi apparently learned of the unauthorized surgery allegation against him even prior to [REDACTED]'s letter because on July 15, he wrote to [REDACTED] stating he understood questions had arisen regarding his decision to perform the procedure, explaining his decision to perform the contested procedure, and setting forth why he believed it fell within his clinical privileges. (J.A. 721-28.) Although [REDACTED]'s July 16 letter does not mention a possible suspension, it does state that CAMC would be investigating the claims that Wahi had again exceeded his authority under his provisional privileges and not complied with the CAMC Bylaws when he failed to notify CAMC that he had relinquished his privileges at another hospital. Wahi had previously been suspended at least three times for violation of his privileges and was not unaware of the consequences. [REDACTED] also informed Wahi that he should respond in writing as soon as possible and address his reappointment before the Credentials Committee at the August 3, 1999 hearing, (J.A. 576), which was rescheduled for August 17 at Wahi's request. Over the next two weeks, Wahi wrote to [REDACTED] and [REDACTED] several times, addressing the charges in writing, and providing documents supporting his position that he had not violated the conditions of his clinical privileges. He also requested access to certain records prior to or during the Credentials Committee meeting. (J.A. 730, 731, 732-41, and 742.) The record shows that CAMC provided Wahi with notice of the most recent allegations against him, and an opportunity to respond to those allegations. CAMC complied with its Procedures Manual in this regard. CAMC suspended Wahi's medical privileges by a letter dated July 30, 1999 from [REDACTED], which recited the best interests of patient care as the reason for the action. (J.A. 586.) However, the record does not support Wahi's contention that CAMC did not inform him more specifically of the reasons for his suspension. On July 30, [REDACTED] and [REDACTED] met with Wahi to inform him of the suspension pending the Credentials Committee's review of his application for reappointment. [REDACTED]'s memorandum of that meeting recites that they informed Wahi that the Credentials Committee and Board of Trustees both recommended he be suspended. [REDACTED] cited Wahi's inability to follow procedural guidelines outlined by the Committee and the Board of Trustees which ensures adequate care and safety of patients, and also told Wahi that when he met with the Credentials Committee, he should be prepared to defend his lack of adherence to the limitations on his privileges as well as his absence of notification of suspension from St. Francis [Hospital]. [19] (J.A. 965.) The suspension letter reiterated the rights due Wahi under Article III of the Procedures Manual for a hearing to challenge that action, and attached a copy for his use. The Credentials Committee then afforded Wahi, by letter of August 13, 1999, the opportunity to review the file for the August 17 meeting for the timeline of events surrounding [his] privileges at CAMC. The letter also emphasized to Wahi that This meeting is your opportunity to present the Committee with additional information that is pertinent to its evaluation of your ethical behavior, clinical competence and clinical judgment in the treatment of patients; compliance with Hospital policies and the Medical Staff Bylaws and Rules and Regulations; behavior in the hospital, your cooperation with medical and Hospital personnel as it relates to patient care or the orderly operation of hospital, and your general attitude toward patients, the Hospital and its personnel; use of the Hospital facilities for your patients; your physical and mental health; your capacity to satisfactorily treat patients as indicated by the results of the Hospital's quality assessment activities or other reasonable indicators of continuing qualifications; your satisfactory completion of such continuing education requirements as may be imposed by law, the Hospital or applicable accreditation agencies; and other relevant findings from CAMC's and the Medical Staff's quality assurance activities. (J.A. 752.) Copies of relevant portions of CAMC's Procedures Manual were attached to the letter. (J.A. 752-57.) A separate letter informed Wahi how the meeting would be conducted, and set out Wahi's rights regarding the meeting. (J.A. 719-20.) The Credentials Committee met on August 17, 1999. Wahi appeared before it and presented his case. The Committee concluded it was unable to identify evidence that Dr. Wahi's clinical competence [and] professional judgment ... are sufficient to recommend ... that he be reappointed to the Medical Staff. [20] (J.A. 645-46.) In particular, the Committee cited the following  Failure to comply with and repeated violation of clinical privileges (§ 3.7 of the Bylaws), including:  Failure to obtain a proctor when required to do so;  Failure to obtain a second opinion when required to do so;  Performance of an operative procedure for which he did not have privileges.  Marginal indications for operative procedures;  Poor decision-making in the care of some patients;  Multiple incident reports surrounding bizarre professional behavior and inappropriate personal behavior among nursing staff;  Failure to comply with responsibilities set forth in the CAMC Bylaws, including providing proper quality of care (§ 3.2), maintaining proper medical records (§ 3.3), and notifying CAMC of the loss of clinical privileges at any other hospital (§ 3.6); and  Failure to keep a current, complete, and timely record of patient care (§§ 2.1 and 2.7 of the Medical Staff Rules and Regulations) (J.A. 550, 552-53). (J.A. 645.) On August 26, 1999, Wahi received the Credentials Committee report and was once again notified of the rights provided in Article III and that he had 30 days to request a hearing. [21] (J.A. 647.) The letter also informed Wahi his suspension remained in effect until the CAMC Board of Trustees acted on his reappointment. (J.A. 647.) On September 8, 1999, Wahi, by counsel, timely requested a hearing as well as a witness list and a number of specified documents. (J.A. 648-53.) On October 18, 1999, CAMC notified Wahi of the members of the hearing panel and asked Wahi to work with the presiding officer to schedule and conduct the hearing in accordance with ... Article III, and again forwarded Wahi the Procedures Manual. [22] (J.A. 654-55, 699-700.) CAMC did not give Wahi a specific witness list, [23] but afforded his counsel access to some of the files requested in the September 8, 1999 letter. CAMC repeatedly requested that Wahi provide available dates for his hearing because the hearing will take a number of days and it was important to select dates well enough in advance that all involved parties can clear their schedules. (J.A. 776.) In over 8 years since his request for a hearing, Wahi has yet to provide CAMC with any dates when he would be available for a hearing. During the following year, the parties negotiated over how the hearing would be conducted. Wahi objected to the composition of the panel, its presiding officer, [24] and the use of any incident or discipline during his medical practice at CAMC that he did not address at the August 17, 1999 Credentials Committee meeting. And while CAMC had opened many of its files to Wahi and his counsel, some items Wahi had requested had not been disclosed due to privacy disagreements, which had not been resolved. The parties also attempted to negotiate a resolution of the matter, including withdrawing Wahi's suspension based on a written statement of the basis for CAMC's actions. However, the parties were unable to reach an agreement. (J.A. 760-83, 118-30.) On November 30, 2000, Wahi filed an action in the West Virginia state court to enjoin his requested hearing unless CAMC met his pre-conditions. Wahi asked the state court to order, inter alia, that his method of selection for the hearing panel be used, that no matters of Wahi's medical practice at CAMC be considered at the hearing except those mentioned in [REDACTED]'s July 30, 1999 letter, and that the court maintain jurisdiction over the administrative hearing. (J.A. 99, 112, 99-114.) The state court rejected Wahi's arguments and dismissed the complaint, stating Wahi's arguments were speculative and [i]t would be premature for the Court to make any determination as to whether or not the notice given to Dr. Wahi satisfies the `fair procedures' requirement. (J.A. 141.) Furthermore, the court noted that the composition of the hearing panel was in conformity with CAMC's Procedures Manual, and that any objections about the hearing panel or the evidence to be considered should be raised before the hearing panel. The court entered its final order of dismissal on December 6, 2001. In the meantime, the West Virginia Board of Medicine filed a complaint against Wahi on September 10, 2001, and set a hearing to determine whether disciplinary action should be taken ... against Dr. Wahi's license to practice medicine. (J.A. 149.) Wahi and the Board of Medicine engaged in protracted litigation, which included Wahi's unsuccessful attempt to halt the proceedings by seeking a writ of prohibition against the Board of Medicine from the Supreme Court of Appeals of West Virginia. On November 10, 2003, the proceedings were dismissed, without a final disposition on the merits of the allegations. (J.A. 147-175, 701.) Wahi made no effort during this time period to pursue a hearing at CAMC. While CAMC argues this was a deliberate choice by Wahi to prevent a hearing that would create a record that could affect the Board of Medicine proceedings, the district court made no finding in that regard, CAMC assigns no error to the lack of a finding, and we therefore do not consider it. The next action in time was the filing of Wahi's complaint in the district court. Lastly, in considering whether the procedures provided by the health care entity are fair under the circumstances, the July 1999 allegations against Wahi cannot be considered in a vacuum. These allegations were simply the latest in Wahi's tumultuous history with CAMC, as the August 26, 1999 Credentials Committee letter set forth. Since his reappointment in 1995, Wahi had been the subject of numerous reports and complaints calling his professional competence and conduct into question. The record shows that these complaints arose from a multitude of discrete incidents, were made by different individuals, and were known to Wahi. After all Wahi had been through the suspension process previously at CAMC, including the prior reports to the NPDB. CAMC investigated and imposed restrictions, including temporary suspensions, as a result of those investigations. Wahi was aware of the consequences for failing to abide by the Bylaws and Procedures Manual. He was not a first-time offender who was unfamiliar with the responsibilities of his position at CAMC or the consequences for his failures in July 1999. (J.A. 130-31, 248-53, 339-97, 496-571.) While CAMC's path to immunity in this case is not a recommended model, it must be evaluated considering all the events which transpired, not just those Wahi views as favorable to him. Had CAMC simply set a prompt hearing, whatever Wahi's objections and efforts to stop it, CAMC may have been within its rights to do so and may have met the first prong of subsection (a)(3). Similarly, CAMC should have followed its Bylaws and the Procedures Manual, and provided Wahi a witness list, even if it had to be later supplemented. However, these failures by CAMC, when viewed in the totality of the circumstances against a measuring stick of objective reasonableness, do not show Wahi met his burden of proof to rebut the presumption of immunity under the HCQIA. Wahi was on notice of the many charges against him, including the detailed Credentials Committee report of August 26, 1999. He was repeatedly notified of his rights and given multiple copies of documents explaining these rights. He was repeatedly asked for dates for a hearing. While CAMC attempted to accord Wahi a hearing in conformity with the Procedures Manual, Wahi seemed more intent on forestalling a hearing than having one. Had Wahi proceeded to a hearing, any complaint about the inadequacy of notice, defective witness list or discovery, the composition of the hearing panel, the conduct of the hearing, or other relevant issues could have been addressed and subjected to judicial review. In the face of Wahi's recalcitrance, it is at the least disingenuous to now claim his right to a hearing was infringed when he has done all he could do not to have a hearing. Viewing the totality of these circumstances in an objectively reasonable manner, we cannot conclude that the district court erred in determining Wahi failed to rebut the presumption that CAMC afforded him other procedures as are fair to the physician under the circumstances. We therefore affirm the district court's holding that CAMC is entitled to immunity under the HCQIA.