HCQIA Immunity, Declaratory Relief, and the Right to Discovery in Peer Review Disputes:
Commentary on Khamamkar, M.D. v. Specialty Surgicare of Las Vegas, L.P.

I. Introduction

The Supreme Court of Nevada’s decision in Khamamkar, M.D. v. Specialty Surgicare of Las Vegas, L.P. (No. 88041, Nov. 21, 2025) addresses a recurring tension in modern health law: the balance between protecting good-faith peer review and preventing abuse of the peer review process to punish or sideline physicians.

At the center of the case is Dr. Rajeev Khamamkar, a long-practicing anesthesiologist whose clinical privileges at Specialty Surgicare of Las Vegas, an outpatient surgery center, were summarily suspended in April 2020—early in the COVID-19 pandemic—after disputes about how the facility conducted temperature screenings. That suspension led to a peer review process, an adverse action reported to the National Practitioner Data Bank (NPDB), and, ultimately, the effective inability of the physician to obtain work at new facilities.

When Dr. Khamamkar sued the surgery center and two key individuals (its medical director, Dr. Stan Freeman, and administrator, Kathy King, R.N.), the defendants invoked the federal Health Care Quality Improvement Act (HCQIA), which grants conditional immunity from monetary damages to entities and individuals engaged in qualifying “professional review actions.” The district court accepted this immunity defense at the outset, before any discovery, granting summary judgment for the defendants and denying the physician’s request for discovery under NRCP 56(d).

The Nevada Supreme Court vacated that judgment and remanded. In doing so, it clarified two important points of law:

1. HCQIA immunity is limited to “liability in damages” and does not bar declaratory relief or other forms of equitable relief.
2. Summary judgment on HCQIA immunity is improper where the record is not “sufficiently developed,” and a physician who makes a proper NRCP 56(d) showing is entitled to at least limited discovery to attempt to rebut the statutory presumption of immunity.

These clarifications significantly shape how peer review litigation will proceed in Nevada, and they refine the interplay between Nevada procedure (especially NRCP 56(d)) and the federal HCQIA framework.

II. Summary of the Opinion

A. Factual Background

Key facts, as framed by the court:

• Dr. Rajeev Khamamkar is a licensed anesthesiologist who held privileges at Specialty Surgicare from 1998 to 2020.
• In early 2020, as COVID-19 emerged, Specialty Surgicare instituted temperature screenings for everyone entering the facility.
• On April 28, 2020, Specialty Surgicare’s medical director, respondent Dr. Stan Freeman, issued a letter summarily suspending Dr. Khamamkar’s privileges, asserting that staff had attempted to take his temperature on April 23 and 24 but he did not comply and did not return Dr. Freeman’s calls.
• On May 12, 2020, Dr. Khamamkar responded by email, asserting he had not refused screening, that his temperature was in fact taken both days, and that his objections concerned the safety of the method used (e.g., multiple use of the same thermometer without disposable caps and inadequate disinfection).
• Meanwhile, on May 4, 2020, the facility’s Medical Executive Committee (MEC), chaired by Dr. Freeman, had already met, continued his suspension indefinitely, and recommended revocation of his privileges, citing:
  • the April 23–24 screening incidents, and
  • two 2019 write-ups related to billing practices and pharmacy lock-box policy.
• An ad hoc hearing committee was convened. The committee:
  • Allowed Dr. Khamamkar to request witnesses but informed him it had no subpoena power, so he could not compel their attendance.
  • He testified in his own defense and presented his theory of retaliation and prior personal conflicts with Dr. Freeman and King.
  • The surgery center presented its own witnesses, whom his counsel cross-examined.
  • At the hearing, the center conceded that his temperature had indeed been taken April 23 and 24, but contended he was disruptive and entered an improper area while waiting for alternative screening.
• The hearing committee orally found that he failed to cooperate with COVID screening, left the pharmacy lockbox unattended, engaged in “false billing practices,” and acted rudely and unprofessionally. It recommended suspension until he completed courses on anger management, billing, and controlled substances safety.
• The MEC adopted these recommendations, added a requirement to reapply for privileges, and the governing body apparently denied his internal appeal.
• The adverse action was reported to the NPDB, and Dr. Khamamkar alleges he has since been unable to obtain work at new surgery centers.

B. Litigation and District Court Ruling

In his complaint, Dr. Khamamkar sought:

• Money damages for wrongful suspension and related harms; and
• Equitable/declaratory relief, including:
  • A declaration that his suspension violated the facility’s bylaws and federal law, and
  • An order requiring the facility to withdraw “all derogatory information” submitted to the NPDB.

The defendants did not answer. Instead, they immediately moved to dismiss or, in the alternative, for summary judgment, invoking HCQIA immunity under 42 U.S.C. § 11111(a)(1).

In response, Dr. Khamamkar:

• Opposed the motion on the merits; and
• Filed an NRCP 56(d) motion, supported by a 17-page affidavit from his counsel, explaining why discovery was necessary to obtain facts exclusively in the defendants’ possession in order to rebut HCQIA immunity.

The district court:

• Denied the NRCP 56(d) motion;
• Granted summary judgment to the defendants; and
• Held that HCQIA immunity barred all of the physician’s claims, including his request for declaratory relief.

C. Nevada Supreme Court’s Holdings

The Supreme Court vacated the judgment and remanded, on two distinct grounds:

1. HCQIA immunity does not bar declaratory relief.
   
   • 42 U.S.C. § 11111(a)(1) provides that professional review bodies and participants “shall not be liable in damages” under federal or state law if the statutory standards are met.
   • The Court emphasized that this language, and prior authority, make clear that HCQIA immunity is limited to damages and does not preclude declaratory or other equitable relief.
   • The district court therefore erred in dismissing the declaratory relief claim on HCQIA grounds.
2. Summary judgment on the remaining claims was premature; the district court erred in denying NRCP 56(d) discovery.
   
   • HCQIA creates a presumption that peer review actions meet the statutory standards, but that presumption is rebuttable.
   • Determining whether the standards of 42 U.S.C. § 11112(a) are met is a fact-intensive, “totality of the circumstances” inquiry.
   • Because no discovery had occurred and key evidence was under the surgery center’s control, the record was not “sufficiently developed” to resolve immunity as a matter of law.
   • Given the detailed NRCP 56(d) showing and the importance of the facts sought to the immunity analysis, the district court should have allowed at least limited discovery before granting summary judgment.

The Court deliberately declined to decide whether HCQIA immunity ultimately applies; instead, it focused on the procedural and legal errors that made the grant of summary judgment improper.

III. Legal Framework and Precedents

A. HCQIA: Purpose and Structure

Congress enacted the Health Care Quality Improvement Act of 1986 (HCQIA), 42 U.S.C. §§ 11101–11152, to encourage effective peer review by granting qualified immunity from money damages to those who participate in professional review actions, while mandating reporting of certain adverse actions to the NPDB.

Under 42 U.S.C. § 11111(a)(1), immunity exists if the peer review action meets the standards set forth in 42 U.S.C. § 11112(a). Section 11112(a) specifies four requirements:

1. The action must be taken “in the reasonable belief that the action was in the furtherance of quality health care”;
2. It must be taken “after a reasonable effort to obtain the facts of the matter”;
3. It 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”; and
4. It must be taken “in the reasonable belief that the action was warranted by the facts known after such reasonable effort to obtain facts and after meeting the [procedural] requirement”.

HCQIA builds in two important evidentiary features:

• A presumption that these four standards are met, “unless the presumption is rebutted by a preponderance of the evidence.”
• An objective standard of reasonableness: whether a reasonable person in the peer reviewers’ position could have believed their actions furthered quality care and were factually and procedurally justified, regardless of subjective motives.

A physician can defeat immunity by proving—by a preponderance of the evidence—that the action failed to satisfy any one of the four criteria.

B. Nevada’s Prior HCQIA Jurisprudence

The Court’s analysis rests heavily on two earlier Nevada cases:

1. Clark v. Columbia/HCA Information Services, Inc., 117 Nev. 468, 25 P.3d 215 (2001)

In Clark, Nevada adopted what the Court here calls an “unusual” summary judgment standard for HCQIA cases. Because of the statutory presumption, the usual presumption in favor of the nonmoving party is modified:

• The defendant (typically the hospital or peer review body) is entitled to summary judgment unless a reasonable fact-finder, viewing the evidence in the light most favorable to the physician, could conclude that the physician has shown, by a preponderance of the evidence, that the peer review action failed at least one of HCQIA’s four standards.

Clark is also significant for recognizing that:

• HCQIA immunity determinations are based on the totality of the circumstances, and
• Retaliatory suspensions—for example, where a physician is disciplined in response to whistleblowing to outside agencies—can, in some circumstances, be so inconsistent with the statutory “reasonable belief” standard that immunity is lost, even where there is “one instance of an objective basis for discipline.”

2. Meyer v. Sunrise Hospital, 117 Nev. 818, 22 P.3d 1142 (2001)

In Meyer, the Court:

• Affirmed summary judgment in favor of a hospital based on HCQIA immunity, but only after the district court had:
  • Denied an early motion to dismiss, and
  • Allowed about a year of discovery before ruling on summary judgment.
• Confirmed that whether HCQIA immunity applies is a question of law for the court to decide “whenever the record is sufficiently developed.”
• Explained that HCQIA provides immunity from damages, not from all forms of relief.
• Observed in a footnote that there will be instances where the subjective motives of the peer review committee are relevant, particularly where they might show that an action was not, in objective reality, taken in furtherance of quality care.

The Nevada Supreme Court in Khamamkar leans on both Clark and Meyer to emphasize:

• The need for a developed record before deciding immunity, and
• The possibility that retaliatory or biased actions, when combined with other evidence (e.g., manufactured or exaggerated charges), may rebut the HCQIA presumption.

C. Other Key Authorities Cited

The opinion references a wide set of federal and state decisions interpreting HCQIA and related issues:

• Kalan v. MedStar–Georgetown Medical Center, Inc., 253 A.3d 123 (D.C. 2021) and Peper v. St. Mary’s Hospital & Medical Center, 207 P.3d 881 (Colo. App. 2008) – for the proposition that a plaintiff need only show that any one of the four § 11112(a) standards was not met to defeat immunity.
• Chudacoff v. University Medical Center of Southern Nevada, 609 F. Supp. 2d 1163 (D. Nev. 2009) – explicitly holding that HCQIA immunity is “immunity from damages only.”
• Aviation Ventures, Inc. v. Joan Morris, Inc., 121 Nev. 113, 110 P.3d 59 (2005) – stating that summary judgment is improper when a party seeks time to conduct discovery necessary to oppose the motion.
• Choy v. Ameristar Casinos, Inc., 127 Nev. 870, 265 P.3d 698 (2011) – emphasizing that where a party seeks NRCP 56(d) relief and demonstrates that its adversary controls the relevant information, denying discovery is generally improper.
• Bryan v. James E. Holmes Regional Medical Center, 33 F.3d 1318 (11th Cir. 1994) – acknowledging Congress’s intent that HCQIA immunity be resolved as early as possible, but only when the record permits.
• Brader v. Allegheny General Hospital, 64 F.3d 869 (3d Cir. 1995) – stressing that the requirement that a physician rebut the presumption by a preponderance of evidence “implies some opportunity to discover relevant evidence.”
• Egan v. Athol Memorial Hospital, 971 F. Supp. 37 (D. Mass. 1997), aff’d, 184 F.3d 361 (1st Cir. 1998) – noting that if peer reviewers “consciously joined” in manufacturing or exaggerating incidents, or were economically motivated to restrain the physician’s practice, they could not reasonably believe their conduct was legitimate peer review.
• Brown v. Presbyterian Healthcare Services, 101 F.3d 1324 (10th Cir. 1996) – affirming denial of HCQIA immunity where a key actor exhibited discrimination, bias, and economic motivation, and the objective facts did not support the charges.
• Freilich v. Upper Chesapeake Health System, Inc., 33 A.3d 932 (Md. App. 2011) – describing HCQIA immunity as a totality-of-circumstances inquiry and recognizing that retaliatory animus could undermine the required reasonable belief in furtherance of quality healthcare.
• Straznicky v. Desert Springs Hospital, 642 F. Supp. 2d 1238 (D. Nev. 2009) and Sternberg v. Nanticoke Memorial Hospital, Inc., 15 A.3d 1225 (Del. 2011) – cited by the defendants for the proposition that a history of disruptive conduct can support qualified immunity.

These authorities collectively frame HCQIA as a regime that strongly favors peer reviewers—via presumptive, objective immunity—but still allows physicians to overcome that immunity when the review process is objectively unreasonable, especially when biased actors manipulate the process or the charges.

IV. The Court’s Legal Reasoning

A. HCQIA Immunity Is Limited to Damages, Not Declaratory Relief

The first clear doctrinal point is textual and straightforward: 42 U.S.C. § 11111(a)(1) states that participants in qualifying professional review actions:

“shall not be liable in damages” under any law of the United States or any State, subject to certain exceptions.

The Nevada Supreme Court underscores several aspects:

• The statute does not say that peer reviewers are immune from all forms of civil liability or from all judicial scrutiny of their actions.
• It speaks only of “damages”—i.e., monetary compensation.
• Prior Nevada and federal decisions have repeatedly recognized this limitation:
  • Meyer described HCQIA as essentially shielding participants from liability in damages, and emphasized that immunity is not absolute.
  • Chudacoff held explicitly that HCQIA “immunity is immunity from damages only.”

Accordingly, even if a peer review body is immune from money damages (e.g., tort damages for wrongful suspension), a court may still:

• Declare whether the peer review action complied with the bylaws or applicable law;
• Potentially order equitable remedies—such as reinstatement of privileges or correction of NPDB reports—if a proper legal basis exists.

By applying HCQIA to bar the declaratory relief claim, the district court misapplied the statute. The Supreme Court corrects this, stating unequivocally that:

“HCQIA only immunizes peer reviewers from money damage claims, not declaratory relief.”

The Court also rejects any suggestion that this argument was waived; the record showed that in the district court, Dr. Khamamkar explicitly argued that HCQIA did not bar equitable or declaratory remedies.

B. The “Unusual” Summary Judgment Standard Under HCQIA

Under normal Nevada summary judgment practice (Wood v. Safeway), courts view the evidence in the light most favorable to the nonmoving party and ask whether genuine disputes of material fact exist.

In HCQIA cases, however, there is a statutory presumption of compliance with § 11112(a). The Supreme Court restates the standard adopted in Clark:

The defendant is entitled to summary judgment unless a reasonable trier of fact, viewing the facts in the light most favorable to the plaintiff, could conclude that the plaintiff has shown, by a preponderance of the evidence, that the defendant’s actions fail to satisfy at least one of the § 11112(a) provisions.

Key implications:

• The physician bears the burden of rebutting the presumption.
• But this burden is assessed under the usual summary judgment lens: the court asks whether a reasonable jury could find that the physician has carried that burden.
• If so, summary judgment is improper; if not, immunity applies as a matter of law.

C. NRCP 56(d) and the Need for Discovery Before Deciding Immunity

The core procedural holding in Khamamkar is that summary judgment on HCQIA immunity was premature because no discovery had occurred, and because the physician had made a detailed showing under NRCP 56(d).

NRCP 56(d) (the Nevada counterpart of Federal Rule of Civil Procedure 56(d)) permits a party opposing summary judgment to request:

• Additional time to obtain affidavits or take discovery, or
• Other relief, if the party “cannot present facts essential to justify its opposition” to summary judgment.

The Nevada Supreme Court relies on Aviation Ventures and Choy:

• Aviation Ventures – summary judgment is improper where a party seeks more time to conduct discovery to compile facts to oppose the motion.
• Choy – this is especially true when the opposing party shows that the moving party controls access to the relevant evidence.

Here:

• The defendants filed a motion to dismiss/for summary judgment without answering and before any discovery.
• All crucial information about the peer review process—internal communications, investigative steps, deliberations, prior incident reports, comparative treatment of other physicians—was in the surgery center’s control.
• Through a detailed 17-page affidavit, counsel for Dr. Khamamkar identified:
  • Specific categories of documents and testimony he needed (for example, evidence of differential enforcement of COVID screening, internal discussion of his safety complaints, and the true nature of the billing/lockbox issues), and
  • Why those facts were essential to test whether the action truly met each of § 11112(a)’s four requirements.

Although Congress intended HCQIA immunity to be resolvable “as early as possible” (Bryan), the Supreme Court stresses that this early resolution is appropriate only “whenever the record is sufficiently developed.” The Court quotes Brader approvingly: requiring a physician to rebut the presumption by a preponderance of the evidence “implies some opportunity to discover relevant evidence.”

Given the absence of any discovery and the importance of facts under the defendant’s control, the Court holds:

• The record was not sufficiently developed to determine HCQIA immunity as a matter of law.
• Under NRCP 56(d), the district court was obliged to allow at least limited discovery directed at the immunity issues before granting summary judgment.

D. Role of Subjective Motives, Retaliation, and “Sham” Peer Review

The defendants argued, and the district court apparently agreed, that evidence of:

• Personal dislike,
• Retaliatory animus, or
• Other subjective bias

is irrelevant to HCQIA’s “reasonable belief in furtherance of quality health care” standard, because the test is objective. They cited Meyer for the proposition that subjective motives alone do not defeat immunity.

The Supreme Court agrees that:

• Subjective bias or animus, by itself, is not enough to overcome HCQIA immunity.

But it then makes two crucial clarifications:

1. The presumption of immunity is rebuttable; it is not absolute.
   The Court restates that a physician can overcome immunity by showing that the peer review action was “objectively unreasonable” under the totality of the circumstances (Clark).
2. Subjective motives can matter as part of that totality, especially when linked to concrete irregularities.
   The Court draws on both Clark and out-of-state HCQIA cases:
   • Clark recognized that a retaliatory motive (e.g., disciplining a whistleblower) can defeat immunity where the true purpose of the action is not quality care, even if some facially plausible basis for discipline exists.
   • Egan, Brown, and Freilich illustrate that when:
     • Bias or retaliation coincides with manufactured or exaggerated charges, or
     • An economically motivated individual manipulates the process,
     a jury could find that peer reviewers lacked a lawful “reasonable belief” that the action furthered quality care.

The Supreme Court therefore indicates that Dr. Khamamkar’s theory—that the charges were inflated or selectively enforced in retaliation for his safety objections and prior disputes, and that key decision-makers dominated the process—could, with evidence, be relevant to rebutting immunity.

While distinguishing Clark factually (because in Clark the physician reported concerns to outside agencies, whereas here he raised concerns internally), the Court still deems Clark “instructive” on the use of subjective motives as part of the broader reasonableness inquiry.

E. Application to the Facts Alleged by Dr. Khamamkar

The Court does not decide whether HCQIA immunity ultimately applies to the defendants. Instead, it explains why the physician is entitled to discovery on key topics that may affect the immunity analysis, including:

• The actual nature of the alleged misconduct.
  The facility conceded at the hearing that his temperature was taken on April 23 and 24, undermining the initial narrative of outright refusal. Discovery may further show whether the written variance reports, internal correspondence, or witness accounts accurately reflect what occurred.
• The handling of his safety concerns.
  Evidence may reveal whether his objections to unsafe temperature-taking practices were:
  • Reasonable and grounded in patient/staff safety, or
  • Treated as disruptive merely because they raised inconvenient issues during early COVID.
• Comparative treatment of other physicians.
  A sworn declaration suggested that he was treated differently from other doctors regarding COVID screening. Discovery could reveal:
  • Whether similarly situated physicians who questioned protocols were not disciplined, or
  • Whether others failed to comply with screening yet were not subjected to comparable sanctions or NPDB reporting.
• The 2019 billing and lockbox incidents.
  He contends these matters were resolved in 2019 and were dredged up only after it became clear that the April 23–24 narrative did not support the suspension. Discovery may shed light on:
  • Whether those issues were legitimately tied to patient care or primarily about fees (which may fall outside HCQIA’s definition of a protected “professional review action” under 42 U.S.C. § 11151(9)), and
  • How they were described and relied upon by the MEC and hearing committee.
• The internal peer review process itself.
  Documents and testimony may indicate:
  • Whether Dr. Freeman and King, who allegedly bore personal animus toward him, dominated the process and the information presented to review bodies;
  • Whether the investigation was thorough and balanced or selectively focused on negative information;
  • Whether he was afforded “adequate notice and hearing” or procedures “fair under the circumstances,” as required by § 11112(a)(3).

If such discovery shows that the charges were exaggerated, selectively enforced, or structurally biased in a way tied to retaliation for protected or safety-related conduct, a jury could find the peer review action was objectively unreasonable and not truly in furtherance of quality healthcare—thus overcoming HCQIA immunity.

V. Complex Concepts Simplified

A. What Is HCQIA?

The Health Care Quality Improvement Act is a federal law with two main goals:

1. Encourage peer review by giving hospitals and physicians some protection from lawsuits when they in good faith discipline or restrict privileges for quality-of-care reasons.
2. Protect patients and other providers by requiring that certain adverse actions (such as revocations or long suspensions of privileges) be reported to the National Practitioner Data Bank (NPDB), so that a doctor with a serious history cannot simply move to another state or facility unnoticed.

In exchange for this protection, peer reviewers must follow basic factual and procedural fairness standards (the four criteria in § 11112(a)).

B. The Four HCQIA Standards in Plain Language

1. Quality care motive: The main reason for the action must reasonably relate to improving or protecting patient care, not punishing a competitor or retaliating against a whistleblower.
2. Reasonable investigation: The hospital must gather facts in a reasonable way—interview witnesses, review charts, consider documentation—before acting.
3. Fair procedures: The physician should get notice of the charges and a fair chance to respond, either through a hearing or some alternative process suited to the situation.
4. Action fits the facts: Based on what the reviewers reasonably learned, the final decision (e.g., suspension, revocation, probation) must be reasonably proportional to the misconduct or risk.

C. What Is NRCP 56(d) (Rule 56(d) Discovery)?

NRCP 56(d) is a safety valve built into summary judgment procedure. It recognizes that:

• A party often cannot fully oppose summary judgment without first getting documents, testimony, or other information that the other side controls.

So, if a party:

• Explains, in a sworn affidavit or declaration, what facts are needed,
• Shows why those facts are important to defending against summary judgment, and
• Shows that those facts are within the other side’s control,

the court should normally:

• Postpone ruling on summary judgment, and
• Allow targeted discovery to obtain those facts.

D. Declaratory vs. Monetary Relief

• Monetary (damage) claims: Claims where the plaintiff asks for money—lost earnings, reputational harm, emotional distress, etc. HCQIA aims to shield peer reviewers from these, if they met the statutory standards.
• Declaratory or equitable relief: Non-monetary remedies. In this case:
  • A declaration that the suspension violated bylaws or law;
  • Orders to correct or withdraw NPDB reports.
  HCQIA does not prohibit these, although whether such relief is ultimately available will depend on other legal doctrines and remedies.

VI. Impact and Broader Significance

A. For Nevada Physicians Involved in Peer Review Disputes

The decision gives physicians several important tools:

1. Preserved access to declaratory and equitable relief.
   Even when HCQIA likely bars money damages, a physician can still:
   • Seek a judicial declaration that the peer review process was unlawful or violated bylaws; and
   • Potentially pursue equitable remedies affecting NPDB reports or hospital privileges.
   This is critical because NPDB reports can effectively end a medical career even if no damages are recoverable.
2. Right to targeted discovery before immunity is decided.
   Physicians who:
   • File a well-supported NRCP 56(d) affidavit, and
   • Show that crucial peer review evidence is held by the hospital
   have a strong argument that they must be allowed some discovery before courts can fairly rule on HCQIA immunity.
3. Framework for challenging “sham” or retaliatory peer review.
   The opinion gathers and endorses the line of cases recognizing that:
   • Retaliatory, biased, or economically motivated actions may, in combination with other evidence (e.g., fabricated, exaggerated, or selectively enforced charges), rebut HCQIA immunity.
   • Subjective motives are not irrelevant; they can be probative of whether the process was objectively unreasonable under the totality of the circumstances.

B. For Hospitals, Surgery Centers, and Peer Review Bodies

The decision sends a clear compliance message to peer review bodies:

• HCQIA remains a powerful shield, but not an absolute one.
  Facilities cannot assume that a bare invocation of HCQIA will end litigation at the pleading stage.
• Documentation and fairness matter.
  To preserve immunity, hospitals should:
  • Maintain clear, contemporaneous documentation of investigations, decision-making, and reasons for actions;
  • Ensure that key decision-makers with personal animus or conflicts of interest do not dominate the process;
  • Apply policies consistently to all physicians, avoiding selective enforcement.
• Expect limited discovery in contested immunity cases.
  While Congress intended early resolution of HCQIA immunity, Nevada now makes clear that:
  • Early resolution is contingent on a sufficiently developed record, and
  • Courts are likely to permit at least focused discovery where the physician plausibly alleges bias, retaliation, or irregularities and shows that relevant evidence resides with the hospital.
• NPDB and reputational stakes heighten judicial scrutiny.
  The serious, career-long impact of NPDB reporting—and the fact that HCQIA immunity is damages-only—may encourage courts to engage more fully with requests for declaratory and injunctive relief concerning the accuracy and lawfulness of reports.

C. For Litigation Strategy in Nevada

Strategically, Khamamkar will influence how both sides litigate peer review disputes:

• Defendants:
  • May still move early for summary judgment on HCQIA immunity, but they should be prepared to:
    • Provide sufficient materials (by declaration, peer review records, etc.) to create a “sufficiently developed” record; and
    • Respond to targeted discovery requests focused on the § 11112(a) criteria.
  • Should separately address—even where they win on damages—why declaratory or equitable relief should be denied on other grounds (e.g., mootness, lack of private right of action for NPDB alterations, or contract limitations).
• Plaintiffs (physicians):
  • Will likely:
    • Plead distinct causes of action for declaratory/injunctive relief, not just damages;
    • File detailed NRCP 56(d) affidavits early, mapping each requested discovery topic to one of the § 11112(a) elements; and
    • Develop evidence of comparative treatment, internal motive, and process irregularities to contest objective reasonableness.

VII. Conclusion

The Nevada Supreme Court’s decision in Khamamkar v. Specialty Surgicare does not decide whether the surgery center and its officials will ultimately enjoy HCQIA immunity. Instead, it does something more foundational: it clarifies how that determination must be made and what HCQIA actually protects.

The Court articulates three central propositions:

1. HCQIA immunity is limited to protection from money damages. It does not shield peer reviewers from declaratory judgments or equitable remedies. Physicians whose careers are harmed by NPDB reports or loss of privileges may still seek non-monetary judicial relief, even when damages claims are barred.
2. HCQIA immunity cannot be decided in a factual vacuum. Because the statute presumes compliance but places on physicians the burden of rebutting that presumption by a preponderance of the evidence, fairness and logic require that physicians be afforded at least limited discovery—especially when all relevant information lies within the hospital’s control.
3. Subjective motives, while not dispositive on their own, can matter under a totality-of-the-circumstances, objective reasonableness inquiry. Retaliation, economic self-interest, or bias, when combined with evidence of manufactured or selectively enforced charges or process manipulation, may suffice to overcome the presumption of immunity.

In the broader landscape of health law, Khamamkar reinforces that HCQIA is a carefully calibrated statute: it encourages robust peer review but does not license sham, retaliatory, or procedurally unfair proceedings. Nevada courts must ensure that immunity is reserved for those peer review actions that genuinely, and reasonably, further the quality of patient care—and that physicians have a meaningful opportunity to prove when that standard has not been met.