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Managed Care: Immunity for Peer Review under HCQIA

Published online by Cambridge University Press:  01 January 2021

Kaley Klanica
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Extract

In Singh v. Blue Cross/Blue Shield of Massachusetts, Inc., the U.S. Court of Appeals for the First Circuit held that defendant Blue Cross/Blue Shield's peer review practices satisfied the immunity standard for professional review actions according to the Health Care Quality Improvement Act (HCQIA), and the First Circuit affirmed the U.S. District Court for the District of Massachusetts's grant of summary judgment in favor of the defendant.

After Blue Cross/Blue Shield merged with Bay State Health Care, Blue Cross began to offer “Bay State Health Care” to former Bay State subscribers. Blue Cross denied the plaintiff, Dr. Kunwar Singh, participation in the Bay State Healthcare Network due to poor utilization review. Singh sought reconsideration, and Blue Cross agreed to audit his practices before making a final decision.

Type
Article
Information
Journal of Law, Medicine & Ethics , Volume 31 , Issue 1 , Spring 2003 , pp. 160 - 161
Copyright
Copyright © American Society of Law, Medicine and Ethics 2003

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References

Singh v. Blue Cross/Blue Shield of Mass., Inc., 308 F.3d 25 (1st Cir. 2002).Google Scholar
42 U.S.C. §§ 11101–11152 (2002); Singh, 308 F.3d at 48.Google Scholar
Singh, 308 F.3d at 28.Google Scholar
Id. at 28–29.Google Scholar
Id. at 29. In a letter to Singh, Blue Cross explained that Singh's utilization rates were excessive, apparently referring to the amount of health care services consumed by Singh's patients. Id. at 29 n. 1.Google Scholar
Id. at 29.Google Scholar
Id. The first audit revealed “excessive use of pain medication,” “unduly lengthy regimens of antibiotic treatment,” and “overutilization of lab tests and office visits.” Id.Google Scholar
See id. at 29–30.Google Scholar
See id. at 30. The second audit revealed “substandard care” in a majority of the cases audited. Id. However, the court noted that the audit was flawed because the cases were not selected at random, and four cases were not Dr. Singh's patients. See id.Google Scholar
Id.Google Scholar
Id.Google Scholar
See Mass. Gen. Laws ch. 111, § 203(c) (2002).Google Scholar
See Singh v. Blue Cross/Blue Shield of Mass., Inc., 182 F. Supp. 2d 164 (D. Mass. 2001).Google Scholar
See Singh 308 F.3d at 31.Google Scholar
Id.Google Scholar
42 U.S.C. § 11112(a) (2002).Google Scholar
Singh, 308 F.3d at 38.Google Scholar
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Id. (citing Sklaroff v. Allegheny Health Educ. Research Found., No. 95–4758, 1996 U.S. Dist. LEXIS 9484, at 8 (E.D. Pa. July 8, 1996)). See also Smith v. Ricks, 31 F.3d 1478, 1487 (9th Cir. 1994) (requiring that peer review proceeding need not resemble a regular trial conducted in court of law).Google Scholar
See Singh, 308 F.3d at 39.Google Scholar