Hospital Services Performed Overseas

"You can't reach over and slap them on the back, but every other aspect of the interaction is preserved," Kalyanpur said.

Nevertheless, Kalyanpur is embroiled in a malpractice case where communication has become an issue. The Grand View Hospital in Sellersville, Pa., and one of its emergency-room doctors is being sued in the case of a man sent home with a diagnosis of diverticulitis. He died hours later when an artery in his heart burst.

The hospital and doctor allege Kalyanpur failed to make it clear that more testing was urgently needed to follow up on a CT scan he read. Kalyanpur denies any wrongdoing.

"Over the past few years, we have worked very hard against the 'anti-India' factor to build up a U.S.-standard company," Kalyanpur wrote in an e-mail. "Our quality reports are saving lives every night in the U.S."

Some also worry about what will happen when mistakes occur. Will a radiologist on another continent be as easily held liable? Could a physician in Bangalore or Beirut be compelled to come to the United States for court proceedings?

"If your radiologist is in Australia or India, I'm not so sure how easy it would be to hold them accountable," said Dennis F. O'Brien of the Maryland Trial Lawyers Association.

Companies offering the services say they have the same malpractice insurance as any U.S.-based radiologist, and such cases would be handled no differently.

"It would be very much in their interest to return to the United States to participate in any proceedings," said Sean Casey, chief executive of Virtual Radiologic Consultants of Eden Prairie, Minn. "This is where their livelihood is. They're not going to risk losing their licenses."