Court Opinion

ID: 4700302
Source: CourtListenerOpinion
Date Created: 2021-07-01 14:03:28.221963+00
Date Added: 2024-06-11T08:06:09.397034
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            DISTRICT OF COLUMBIA COURT OF APPEALS

                                  20-CV-146

                     MOHAMMED KALAN, M.D., APPELLANT

                                       V.

      MEDSTAR-GEORGETOWN MEDICAL CENTER, INC., ET AL., APPELLEES.

                         Appeal from the Superior Court
                          of the District of Columbia
                                (CAB-4039-19)

                      (Hon. Robert R. Rigsby, Trial Judge)

(Argued April 27, 2021                                       Decided July 1, 2021)

      M. Natalie McSherry, with whom John A. Bourgeois and Geoffrey H. Genth
were on the brief, for appellant.

      Brian L. Schwalb, with whom Moxila A. Upadhyaya and David A. Levie were
on the brief, for appellees.

      Before EASTERLY, MCLEESE, DEAHL, Associate Judges.

      EASTERLY, Associate Judge:       Dr. Mohammed Kalan sued MedStar-

Georgetown University Hospital (MGUH) in Superior Court after the hospital

terminated his clinical privileges. The Superior Court granted MGUH’s motion to

dismiss under Superior Court Rule of Civil Procedure 12(b)(6) on the ground that
                                          2

the hospital was immune from a suit for damages under the federal Health Care

Quality Improvement Act (HCQIA) and from a suit for any type of relief under the

District of Columbia’s Health-Care Peer Review Amendment Act (HCPRAA) of

1992. Reviewing that ruling de novo and accepting the detailed allegations in Dr.

Kalan’s complaint as true as we must, we conclude that dismissal of Dr. Kalan’s suit

was unwarranted. Even under the HCQIA, which contains a rebuttable presumption

that a health-care entity cannot be held liable for the actions of its professional

review bodies, the fact-intensive assessment of whether the professional review

body has satisfied the substantive and procedural standards that justify damages

immunity under the statute is generally better addressed at later stages of litigation;

and under the HCPRAA, which contains no such presumption, a ruling that a health-

care entity is immune from suit is generally infeasible at the pleading stage. Thus,

we vacate the trial court’s decision and remand for further proceedings.
                                           3

                       I.        Facts and Procedural History

      Dr. Kalan, an academic surgeon, 1 was granted clinical privileges at MGUH,

allowing him to treat patients there, in 1999. According to MGUH’s bylaws, a

physician must renew their clinical privileges every two years. 2 Given that Dr.

Kalan was permitted to practice at the hospital until 2017, it appears MGUH renewed

his privileges multiple times.

      According to Dr. Kalan’s complaint, in 2016, the hospital’s Surgical Practice

Committee, a body that monitors the performance of surgeons, reviewed one case in

which another doctor had raised concerns about whether Dr. Kalan adequately

advised the patient (denominated “Patient 3”) about the risks and benefits of

different surgical procedures. The Committee did not notify Dr. Kalan of its review

or request his input about this case. The Committee ultimately decided that, going

forward, Dr. Kalan would be required to refer this type of case “for review by a

faculty member that has privileges to perform that particular operation” and that a

      1
        Dr. Kalan does not define this term, but it appears to mean that he both treats
patients and teaches medical students.
      2
        For this proposition we rely on MGUH’s bylaws, which the MGUH
defendants attached to their memorandum of law in support of their motion to
dismiss and which are included in the joint appendix submitted to this court.
                                          4

“focus practice plan evaluation” would be put in place to evaluate Dr. Kalan’s

performance for the next six months. Dr. Kalan was apparently notified of this

decision after the fact and requested additional information. The Committee did not

respond to his request, and the focus practice plan evaluation was never

implemented. Later in 2016, the Committee reviewed another one of Dr. Kalan’s

cases (“Patient 4”), believing that a bladder injury had occurred during surgery,

when in fact “qualified experts” later determined that it was not possible to say when

the injury occurred. Again, Dr. Kalan was not given an opportunity to present to the

Committee or respond to its concerns; instead, at the culmination of this meeting,

the leadership of the hospital (defendants Dr. Lisa Boyle and Dr. Michael

Sachtleben) endorsed a plan to terminate Dr. Kalan’s privileges in the upcoming

renewal cycle.

      Dr. Kalan applied to renew his clinical privileges in 2017. Two internal

bodies responsible for reviewing such applications, the Credentials Committee and

the Medical Executive Committee, recommended in turn that Dr. Kalan’s privileges

be terminated, based in part on patient care concerns from the two cases in 2016.

Both committees based their decisions exclusively on oral reports from MGUH

leadership (defendant Dr. Boyle and the head of the Medical Executive Committee,

Dr. Cirrelda Cooper) and others who had no personal knowledge of Dr. Kalan’s
                                         5

patient care; neither committee reviewed any patient records or other documents.

Several of the members of the Medical Executive Committee were direct

competitors of Dr. Kalan. Dr. Kalan was not given notice of either Committee

meeting or an opportunity to be heard.

       Two days after the Medical Executive Committee meeting, the Quality and

Safety Professional Affairs Committee (QSPAC) convened by phone to discuss the

previous committees’ recommendations not to renew Dr. Kalan’s credentials.

Again, Dr. Kalan was not given notice of the meeting or an opportunity to be heard.

As with the Credentials Committee and the Medical Executive Committee meetings,

Dr. Boyle “commandeered” the QSPAC meeting. The QSPAC voted not to renew

Dr. Kalan’s privileges based in part on the false representation that there had been

concerns about the care he provided since 2005. A letter from the QSPAC, dated

May 30, 2017, was emailed to Dr. Kalan on June 8, 2017, informing him that his

privileges were being terminated by virtue of not being renewed on June 9, 2017.

Also on June 8, 2017, defendant Dr. Boyle telephoned a patient of Dr. Kalan’s who

was scheduled for surgery the next day and informed the patient that Dr. Kalan no

longer had privileges at MGUH and could not perform the procedure.
                                          6

      Dr. Kalan appealed the denial of his application to MGUH’s Professional

Review Committee (PRC). The PRC held a hearing on January 19, 2018. Dr. Kalan

objected to the composition of the PRC on the grounds that some members were his

economic competitors or harbored personal bias against him. Although the PRC

determined that Dr. Kalan had not breached the standard of care for Patient 3, it

upheld the termination of his privileges, relying on allegations not considered by the

QSPAC, “some of which were unsubstantiated or hearsay” and at least one of which

was made anonymously. According to Dr. Kalan, the PRC proceeding was a “trial

by ambush,” and the reliance on allegations not previously considered was an

implicit admission that the earlier allegations did not support termination of his

privileges.

      A Special Committee of MGUH’s Board of Directors approved the PRC’s

decision. Thereafter, MGUH notified the National Practitioner Data Bank that the

hospital had revoked Dr. Kalan’s privileges.        The notice explained that the

revocation was due to “failure to provide medically reasonable and/or necessary

items or services”; “patient neglect”; and “substandard or inadequate care.”

      Dr. Kalan filed a complaint in Superior Court, naming MGUH and a number

of its officers as defendants in their personal capacity and as agents of MGUH (“the
                                          7

MGUH defendants”) and asserting various tort and contract claims. In addition to

damages, he requested injunctive relief in the form of an order directing the hospital

to reinstate his clinical privileges. The MGUH defendants did not answer the

complaint and instead filed a motion to dismiss under Rule 12(b)(6). The MGUH

defendants argued that (1) Dr. Kalan could sue the hospital only for failing to follow

its bylaws, (2) he had failed to state viable claims against them, and (3) they were

immune from suit under federal and D.C. law. The MGUH defendants requested a

hearing on their motion.

      In his opposition, Dr. Kalan argued that his “specific factual allegations, the

truth of which is accepted for purposes of Defendants’ Motion, bar Defendants from

persuasively arguing, as a matter of law at the pleading stage, that Defendants are

statutorily immune from Dr. Kalan’s claims.” Dr. Kalan also argued that he had

pled viable claims against the MGUH defendants but alternatively asked for leave

to amend his complaint.      Lastly, Dr. Kalan joined the MGUH defendants in

requesting that the trial court hold a hearing on the MGUH defendants’ motion.

      In their reply, the MGUH defendants renewed their arguments that Dr.

Kalan’s complaint should be dismissed, this time asserting dismissal should be with
                                            8

prejudice. Although they did not renew their request for a hearing, they did not

oppose Dr. Kalan’s request.

      Without holding a hearing, the trial court granted the MGUH defendants’

motion and dismissed Dr. Kalan’s complaint. Relying on this court’s decision in

Balkissoon v. Capitol Hill Hosp., 558 A.2d 304 (D.C. 1989), the court first

determined its review of this case was “largely limited to reviewing whether

Defendants followed the procedures in the hospital’s bylaws when they decided not

to renew Plaintiff’s admitting privileges.” 3        With this foundation, the court

concluded that it lacked the authority to grant Dr. Kalan the injunctive relief he

requested but that its “limited review” did not prevent Dr. Kalan from bringing the

tort and contract claims pled in his complaint. The court determined that MGUH

was immune from a suit for damages, however, because the facts alleged in Dr.

      3
         The trial court framed Balkissoon as a decision that limited a doctor-
plaintiff’s claims. But see 558 A.2d at 307, 310 (explaining that where the plaintiff
had “claimed that the Hospital had wrongly denied him staff privileges and
substantive and procedural due process by denying his application for reappointment
without following the procedures in its bylaws,” the trial court had erred in granting
the defendant’s motion for summary judgment, because even though the plaintiff
“may not have asserted facts from which we could conclude that the decision of the
Hospital was ‘state action,’ such as to require that the Hospital afford appellant due
process in the constitutional sense,” the hospital was still obligated to afford “at least
all the process and protections encompassed in its bylaws” (emphasis added)).
                                         9

Kalan’s complaint were insufficient to rebut the presumption that the professional

review action 4 in his case satisfied the requirements of 42 U.S.C. § 11112 and

because MGUH had complied with its bylaws’ internal review procedures when

terminating Dr. Kalan’s privileges. Lastly, the court determined that the MGUH

defendants were also immune from suit under what the trial court understood to be

the “substantially similar” D.C. Health-Care Peer Review Amendment Act of 1992,

D.C. Code § 44-801 et seq. (2012 Repl.). This appeal followed.

          II.   The Federal and Local Peer Review Immunity Statutes

      “Peer review, the process by which physicians and hospitals evaluate and

discipline staff doctors, has become an integral component of the health care system

in the United States.” Bryan v. James E. Holmes Reg’l Med. Ctr., 33 F.3d 1318,

1321 (11th Cir. 1994).     In 1986, Congress passed the Health Care Quality

Improvement Act to promote “effective professional peer review,” 42 U.S.C.

§ 11101(3), and to facilitate “interstate monitoring of incompetent physicians,”

Austin v. McNamara, 979 F.2d 728, 733 (9th Cir. 1992). Recognizing that “[t]he

threat of private money damage liability . . . unreasonably discourages physicians

      4
       The court referenced a number of MGUH committees, but it did not identify
which committee action (or actions) it understood to be protected under the HCQIA.
                                           10

from participating in effective professional peer review,” 42 U.S.C. § 11101(4), the

HCQIA provides a countervailing incentive in the form of damages immunity when

“professional review actions” meet certain substantive and procedural standards.

The statute is “designed to facilitate the frank exchange of information among

professionals conducting peer review inquiries without the fear of reprisals in civil

lawsuits” for damages, but it also “attempts to balance the chilling effect of litigation

on peer review with concerns for protecting physicians improperly subjected to

disciplinary action.” Bryan, 33 F.3d at 1322; see also id. n.3 (explaining Congress

restricted the immunity provision after concerns were raised that it “might be abused

and serve as a shield for anti-competitive economic actions under the guise of quality

controls” (internal citation omitted)). As an indication of the difficulty of this

enterprise, “the statutory scheme is somewhat convoluted.” Id. at 1322.

      The HCQIA defines “professional review action” as

      [A]n 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.
                                          11

42 U.S.C. § 11151(9). The HCQIA defines “professional review body” in relevant

part as “any committee of a health care entity [such as a hospital 5] which conducts

professional review activity [such as ‘determin[ing] whether [a] physician may have

clinical privileges’ with a hospital 6], and includes any committee of the medical staff

of such an entity when assisting the governing body in a professional review

activity.” 42 U.S.C. § 11151(11).

      Employing these definitions, the immunity provision of the HCQIA, 42

U.S.C. § 11111(a)(1), provides that a professional review body or, inter alia, “any

person acting as a member or staff to the body . . . [or] any person who participates

with or assists the body with respect to the action[] shall not be liable in damages”

under federal or state law for a professional review action if that 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
      reasonable effort to obtain facts and after meeting the requirement of
      paragraph (3).

      5
         42 U.S.C. § 11151(4)(A)(i), (5) (defining “health-care entity” and
“hospital”).
      6
          42 U.S.C. § 11151(10)(A).
                                          12

42 U.S.C. § 11112(a)(1)–(4). “A health care entity is deemed to have met the

adequate notice and hearing requirement of subsection (a)(3) with respect to a

physician if [certain] conditions are met (or are waived voluntarily by the

physician),” such as notice of a proposed action and reasons for the action, notice of

a hearing (including a list of testifying witnesses), the right to representation by

counsel, and the right to cross-examine witnesses. 42 U.S.C. § 11112(b). But the

failure to provide all of the process outlined in subsection (b) is not per se a failure

to satisfy (a)(3). Id.

       The HCQIA creates a presumption that “[a] professional review action [has]

met the . . . standards” set forth in 42 U.S.C. § 11112(a)(1)–(4) and places the burden

on a plaintiff to rebut that presumption “by a preponderance of the evidence.” 42

U.S.C. § 11112(a); see also Brader v. Allegheny Gen. Hosp., 64 F.3d 869, 879 (3d

Cir. 1995). Because a professional review action must “meet[] all the standards

specified in section 11112(a)” in order for the professional review body to be

immune from damages under the statute, 42 U.S.C. § 11111(a)(1), “[t]o defeat

immunity, a plaintiff need only show that any one of these four standards was not

met,” Peper v. St. Mary’s Hosp. & Med. Ctr., 207 P.3d 881, 887 (Colo. App. 2008)

(ellipsis and internal quotation marks omitted).
                                          13

      Six years after Congress enacted the HCQIA, the D.C. Council enacted the

D.C. Health-Care Peer Review Amendment Act of 1992, D.C. Code § 44-801 et seq.

The HCPRAA provides that

      [n]o peer review body or member thereof, or person acting as its staff,
      or who participates with or assists such a body or member, operating in
      the District of Columbia shall be liable to any person for damages or
      equitable relief by reason of conducting or taking peer review if the
      peer review was within the scope of the functions of the peer review
      body and if the peer review body or the member acted in the reasonable
      belief that the peer review was warranted by the facts known after
      reasonable effort to obtain the facts of the matter.

D.C. Code § 44-803. “Peer review body” is defined in relevant part as “a committee

. . . of a health-care facility or agency . . . that engages in peer review,” D.C. Code

§ 44-801(6), such as the “renewal [or] denial . . . of clinical privileges to provide

health-care services at a health-care facility or agency,” D.C. Code § 44-801(5)(B).

And “health-care facility or agency” is defined as “a facility, agency, or other

organizational entity as defined in [D.C Code] § 44-501,” which includes a hospital.

D.C. Code § 44-801(2); D.C. Code § 44-501(a)(9).

      This court has not previously published a decision either interpreting the

HCQIA or analyzing immunity from suit for peer review actions under the

HCPRAA.
                                          14

                                   III.   Analysis

      The trial court dismissed Dr. Kalan’s complaint at the pleading stage based on

its determination that the MGUH defendants were immune from suit for damages

under the HCQIA and from suit for any type of relief under the HCPRAA. The trial

court had already rejected Dr. Kalan’s request for injunctive relief on other grounds;

Dr. Kalan has not challenged that ruling on appeal. Thus the question before us is

whether the trial court correctly determined that MGUH defendants enjoyed

damages immunity under the federal and District of Columbia statutes. We review

this legal ruling de novo. Poola v. Howard Univ., 147 A.3d 267, 276 (D.C. 2016)

(“This court reviews de novo a dismissal under Super. Ct. Civ. R. 12(b)(6) for failure

to state a claim on which relief can be granted.” (emphasis omitted)); see also Peper,

207 P.3d at 888 (holding that HCQIA immunity is a “de novo legal question”

(internal quotation marks omitted)). In so doing, we examine the complaint in the

same manner as the trial court was obliged to examine it, accepting the factual

allegations as true and drawing all reasonable inferences in favor of Dr. Kalan as the

plaintiff. Poola, 147 A.3d at 276. For the reasons we detail below, we conclude that

the trial court did not have a basis, at least at this point in the proceedings, to
                                          15

determine that the MGUH defendants were entitled to damages immunity under

either federal or local law. 7

                                 A. Immunity under the HCQIA

       We begin our analysis of the trial court’s 12(b)(6) ruling regarding HCQIA

immunity by highlighting that the statute does not confer “a right to avoid standing

trial” or even a right not to be sued. Bryan, 33 F.3d at 1331 n.3 (citing Decker v.

IHC Hosps., Inc., 982 F.2d 433, 436 (10th Cir. 1992); Manion v. Evans, 986 F.2d

1036, 1042 (6th Cir. 1993)). The HCQIA by its plain language protects healthcare

entities from being held “liable in damages.” 42 U.S.C. § 11111(a). The statute

confers this protection by establishing a presumption that professional review

actions taken by professional review bodies meet the substantive and procedural

standards set forth in 42 U.S.C. § 11112(a)(1)–(4). But the statute also permits that

presumption to be rebutted by a preponderance of the evidence.

       7
        We have not been asked to separately determine if the trial court abused its
discretion under Superior Court Rule of Civil Procedure 12-I(h) when it ruled on the
MGUH defendants’ motion to dismiss without holding a hearing as both parties had
requested. But given the complexity of the immunity question, see Bryan, 33 F.3d
at 1322, and the lack of guiding case law from this court, see supra Section II, we
have little doubt that the trial court would have been better served by holding a
hearing before ruling on the MGUH defendants’ motion to dismiss.
                                         16

      At the 12(b)(6) stage, a plaintiff is generally entitled to rely on his complaint

and need only allege “enough facts to state a claim to relief that is plausible on its

face.” Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007); accord Potomac Dev.

Corp. v. District of Columbia, 28 A.3d 531, 544 (D.C. 2011) (“When there are well-

pleaded factual allegations, a court should assume their veracity and then determine

whether they plausibly give rise to an entitlement to relief.” (quoting Ashcroft v.

Iqbal, 556 U.S. 662, 679 (2009)). Further, the requirement that a plaintiff rebut the

presumption of damages immunity under the HCQIA by showing that a hospital has

failed to satisfy one or more of the four standards set forth in § 11112(a) suggests

that a trial court should conduct a fact-intensive assessment of the

“reasonable[ness]” of a hospital’s actions and the “adequa[cy]” of its procedures

“under the circumstances,” 42 U.S.C. § 11112 (a)(1)–(4), which likely will require

discovery and development of the record.         Courts have thus concluded that

evaluating whether a health-care entity is entitled to immunity under the HCQIA is

a task generally better suited for resolution at the summary judgment stage—see,

e.g., Brader, 64 F.3d at 879 (explaining that the provision “[u]nder the HCQIA,

[where] professional review actions are presumed to meet the required standard

unless that presumption is rebutted by a preponderance of the evidence . . . implies

some opportunity to discover relevant evidence” (internal quotation marks and

citations omitted)); Zamanian v. Jefferson Par. Hosp. Serv. Dist. No.2, 2017 WL
                                            17

3480993, at *5 (E.D. La. Aug. 14, 2017) (declining to grant motion to dismiss where

the plaintiff alleged detailed facts about only one of the immunity factors related to

adequate notice and process and providing “[p]laintiff with an opportunity to

conduct further discovery given that this matter is still in the early stages of litigation

and immunity is often invoked on a motion for summary judgment, not a motion to

dismiss” (internal quotation marks omitted)), aff’d, 747 F. App’x 982 (5th Cir.

2019)—and may even be delayed until after trial, see, e.g., Bryan, 33 F.3d at 1332

& n.25 (noting that the American Medical Association, appearing as amicus, had

taken the position that “[u]nder the HCQIA, the vast majority of lawsuits challenging

peer review proceedings should be dismissed at the summary judgment stage” and

concluding that “although immunity may be determined at the summary judgment

stage, resolution of that issue may be deferred until or after trial if the standards of

[Federal Rule of Civil Procedure] 56 cannot be satisfied”).

      We endorse this approach and conclude that where a plaintiff has alleged

sufficient facts in his complaint to call into question whether standards for

professional review actions set forth in the HCQIA were satisfied, the trial court

should defer consideration of immunity to the evidentiary stage of the case. 8 We

       8
        We recognize that HCQIA immunity “may be resolved whenever the record
in a particular case becomes sufficiently developed,” Bryan, 33 F.3d at 1332, and
                                          18

turn to examine whether Dr. Kalan alleged sufficient facts in his complaint to survive

a motion to dismiss on HCQIA immunity grounds.

      In his complaint, Dr. Kalan discussed the actions of a number of advisory and

decisionmaking committees within MGUH. The trial court never identified which

MGUH committees it understood to be “professional review bodies” engaged in

protected “professional review actions” under the HCQIA. It appeared to assume

that all of the MGUH committees so qualified. Because these committees all appear

to take “an action or [make a] recommendation . . . based on the competence . . . of

an individual physician and which affects (or may affect) adversely the clinical

privileges . . . of the physician,” 42 U.S.C. § 11151(9), we proceed on the same

assumption.

      Examining Dr. Kalan’s complaint, we conclude he pleaded sufficient facts to

demonstrate at least that these committees did not meet the HCQIA standards set

forth in 42 U.S.C. § 11112(a)(2) (requiring “a reasonable effort to obtain the facts of

we erect no bar to dismissal where a defendant has failed to allege sufficient facts in
his complaint to indicate that he is capable of rebutting the presumption of immunity.
Id. (acknowledging “Congress clearly intended HCQIA to permit defendants in suits
arising out of peer review disciplinary decisions to file motions to resolve the issues
concerning immunity from monetary liability as early as possible in the litigation
process”).
                                         19

the matter”) and (3) (requiring “adequate notice and hearing procedures”). These

adequately pled deficiencies alone precluded the trial court from granting the

MGUH defendants immunity at this juncture. See, e.g., Brader, 64 F.3d at 879

(concluding that if “extensive allegations” in the plaintiff’s complaint regarding

improprieties in the peer review process were accepted as true, then “defendants

would not be entitled to HCQIA immunity,” and thus declining to affirm dismissal

on this ground). 9

                               1. 42 U.S.C. § 11112(a)(2)

      The trial court determined that “though” Dr. Kalan had “summarily allege[d]”

that MGUH’s professional review committees did not make “reasonable efforts to

obtain the facts of the matter” as required under section 11112(a)(2), “the facts as

presented” in his complaint did not support this claim. We cannot agree. Dr. Kalan

detailed the various stages of the peer review process in his complaint and asserted

that the first two committees in the credential renewal process—the Credentials

      9
        Dr. Kalan argues that he adequately pled that none of the standards set forth
in 42 U.S.C. § 11112(a)(1)–(4) were satisfied. But because we determine he carried
his burden to rebut the presumption of immunity by making well-pleaded allegations
that two standards were not met, we need not address the remainder.
                                         20

Committee and the Medical Executive Committee—considered only oral hearsay

reports from MGUH leadership and did not review any patient records or review any

other evidence from anyone with personal knowledge. 10 Dr. Kalan further alleged

that the QSPAC, the third committee in the sequence and the actual decisionmaker

that denied renewal of his privileges, (1) convened only two days after the Medical

Executive Committee meeting and (2) was, like the prior two committee meetings,

“commandeered” by Dr. Boyle (who had no personal knowledge and who harbored

bias against Dr. Kalan), thus supporting an inference that no additional investigation

was done before a predetermined decision was reached. Lastly, according to Dr.

Kalan, none of these committees asked him for his input, which might be considered

part of a reasonable investigation.

      The MGUH defendants argue in their brief to this court that the investigation

by the various committees was reasonable and that “each action . . . was taken only

after [Dr. Kalan’s] cases and level of care were analyzed.” As support for this

      10
         The trial court noted that “there is nothing in the record before the Court
that suggests the Credentials Committee did not review Plaintiff’s extensive
application” for renewal of his privileges. But if we accept Dr. Kalan’s assertions
as true—in particular his assertions that he did not have notice that the committees
were meeting and discussing the quality of his care of specific patients—then his
application to renew his privileges would have no reason to provide facts related to
those patients.
                                           21

assertion, they reference passages in Dr. Kalan’s complaint stating that the quality

of his care “was discussed” in the various committee meetings, but they ignore that

Dr. Kalan sufficiently alleged that these discussions were not based on adequate

inquiry and information. The MGUH defendants also argue that “the decision to not

renew [Dr. Kalan’s] privileges did not become final until after the Hospital

concluded its full review process,” which included the PRC hearing “where Plaintiff

was represented by counsel and was given an opportunity to present evidence and

arguments.” The MGUH defendants provide no support for the proposition that

where multiple professional review bodies are involved, some inquiry by the last in

the line will compensate for inadequate efforts to obtain facts before the decision to

terminate privileges was made and took effect. And the plain text of the statute

contradicts it. See 42 U.S.C. § 11112(a)(2) (requiring that, to be covered by the

HCQIA, “a professional review action must be taken . . . in the reasonable belief that

it is in the furtherance of quality health care . . . after a reasonable effort to obtain

the facts of the matter” (emphasis added)); 42 U.S.C. § 11151(9) (defining

“professional review action” in the singular as “an action or recommendation of a

professional review body . . . .”). In any event, their argument confuses the

obligation of a professional review body to undertake reasonable inquiry under 42

U.S.C. § 11112(a)(2) with the obligation to provide adequate notice and hearing

procedures under 42 U.S.C. § 11112(a)(3).
                                          22

                                2. 42 U.S.C. § 11112(a)(3)

      Even as the trial court acknowledged that Dr. Kalan had alleged that “he was

not permitted to present testimony or evidence” at the meetings of the Credentials

Committee, Medical Executive Committee, or the QSPAC, the court determined that

“there was adequate notice and hearing procedure.” The court reasoned that (1)

MGUH’s bylaws do not allow for a physician to be given notice or an opportunity

to be heard at these committee meetings, and (2) Dr. Kalan was given notice and an

opportunity to be heard before the PRC. 11 Neither of these rationales withstands

scrutiny.

      First, as the trial court effectively acknowledged, Dr. Kalan plausibly and

nonconclusorily alleged in his complaint that MGUH terminated his privileges

without “adequate” or “fair” notice or hearing procedures. 42 U.S.C. § 11112(a)(3).

Dr. Kalan alleged that (1) he had no knowledge of the proceedings before the

Credentials Committee, the Medical Executive Committee, or the QSPAC at the

      11
          The trial court also determined that Dr. Kalan “provided no facts” to support
his allegations that the PRC was compromised by conflicts of interest. In his brief
to this court, Dr. Kalan appears to only raise these alleged conflicts as evidence that
the MGUH defendants failed to follow MGUH’s bylaws, and not in relation to his
challenge to the trial court’s immunity ruling under the HCQIA. Accordingly, we
do not address this part of the court’s analysis.
                                         23

time they were taking place; (2) the first time he received notice that a decision had

been made (by the QSPAC) not to renew his privileges was on June 8, the day before

his privileges were terminated on June 9; and (3) the hospital notified one of his

patients on June 8 that Dr. Kalan would be unable to perform a scheduled surgery

the following day. The fact that MGUH’s bylaws did not require that Dr. Kalan be

given notice of and an opportunity to be heard at any of the committee proceedings

that preceded his termination is beside the point. The HCQIA does not confer

immunity on health-care entities who conform their peer review processes to their

bylaws; it confers immunity on health care entities if the particular professional

review action at issue was taken in accordance with certain standards. Poliner v.

Tex. Health Sys., 537 F.3d 368, 380 (5th Cir. 2008) (“HCQIA immunity is not

coextensive with compliance with an individual hospital’s bylaws. Rather, the

statute imposes a uniform set of national standards.”). Just as “failure to comply

with hospital bylaws does not defeat a peer reviewer’s right to HCQIA immunity

from damages,” id. at 381, MGUH’s professed fidelity to its bylaws in determining

whether to renew Dr. Kalan’s privileges does not insulate the MGUH defendants

from liability for HCQIA purposes. 12

      12
         Citing our decision in Balkissoon, Dr. Kalan argues that the MGUH
defendants violated the hospital’s bylaws and acted arbitrarily and capriciously in
deciding not to renew his privileges. Because these arguments go to the merits of
                                         24

      Second, it is hardly dispositive of the immunity inquiry that Dr. Kalan was

given a PRC hearing more than six months after his privileges were terminated. The

HCQIA peer review standards expressly contemplate a hearing before any

professional review action—broadly defined to include both “action[s]” and

“recommendation[s],” 42 U.S.C. § 11151(9)—is taken. 13            See 42 U.S.C. §

11112(a)(3) (“[A] professional review action must be taken . . . after adequate notice

and hearing procedures are afforded . . . .” (emphasis added)). See Brandner v.

Providence Health & Servs.–Wash., 394 P.3d 581, 595–96 (Alaska 2017)

(determining that even though a hospital provided physician a post-termination

hearing, hospital’s “failure to give [physician] the slightest opportunity to be heard

prior to terminating his privileges—as required by § 11112(a)(3)—preclude[d]

HCQIA immunity” (emphasis added)).

his claims and not to whether the MGUH defendants enjoyed damages immunity,
we do not address them here.
      13
          The MGUH defendants appear to urge us to conclude that the pre-
termination process—the meetings of the Credentials Committee, the Medical
Executive Committee, and the QSPAC—which were conducted without Dr. Kalan’s
knowledge, in conjunction with the post-termination process in which he
participated, was covered by the safe harbor “fair . . . under the circumstances”
language of 42 U.S.C. § 11112(a)(3). As discussed above, we disagree that distinct
professional review actions can be evaluated under the HCQIA as an amalgamated
mass as the MGUH defendants propose. See supra Section III.A.1. But even if the
statute permitted it, the MGUH defendants’ argument would be impossible to
evaluate without more factual development.
                                           25

       For these reasons, we conclude that the trial court erred in determining that

Dr. Kalan’s complaint could be dismissed because the MGUH defendants were

entitled to damages immunity under the HCQIA. Dr. Kalan alleged sufficient facts

in his complaint to contest that the standards set forth in the HCQIA were satisfied

in the professional review actions related to the termination of his clinical privileges;

thus he indicated that, if his allegations are substantiated at the evidentiary stage, he

could rebut the presumption that the MGUH defendants were immune from a suit

for damages. Whether in fact he proves able to do so is a question to be resolved at

a later time.

                            B. Immunity under the HCPRAA

       The trial court found that MGUH was also immune under D.C. Code § 44-

803, observing that “[t]he requirements for immunity under [the District] statute are

substantially similar to those set forth under 42 U.S.C. § 11112.” The plain text of

these provisions are quite different, however. See supra Section II. In particular,

the HCPRAA lacks one critical feature of the HCQIA: the HCPRAA contains no

rebuttable presumption that the procedural standards for peer review have been met

and immunity is warranted. Without such a presumption, we discern no basis for a

determination at the pleading stage that the MGUH defendants were immune from
                                        26

a suit for damages under the HCPRAA; instead, the MGUH defendants must plead

and prove their immunity under the statute as a defense. Cf. Bryan, 33 F.3d at 1333

(explaining that “the presumption language in [the] HCQIA means that the plaintiff

bears the burden of proving that the peer review process was not reasonable”); Minch

v. District of Columbia, 952 A.2d 929, 936–37 (D.C. 2008) (observing that, in the

context of absolute official immunity, “the burden of establishing that the official

function in question merits absolute immunity rests on the defendant official”

(internal quotation marks omitted)).

                                *            *            *

       For the foregoing reasons we reverse and remand for further proceedings

consistent with this opinion.

                                                          So ordered.