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Insurance Plan Applications and Denials

Of critical importance to every physician that seeks employment by a hospital system or medical practice is her ability to become “credentialed” with a hospital with privileges or with an insurance plan for purposes of participating in the plan’s panel or network of physicians.  Typically, physician employment agreements will condition employment upon the physician’s ability to obtain and maintain the credentialing necessary for the employer’s patient servicing and billing purposes.   While the credentialing process may often seem like little more than the required “paperwork,” the stakes are often much higher than is apparent from the routine nature of this undertaking.  Where credentialing is denied, the facts of the denial can result in various adverse consequences, which may range from lost employment with all the attending personal consequences and inconvenience, to permanently having to answer “yes” and explain on future professional applications, whether for other credentialing purposes, employment or medical licensure.   Under some such circumstances, the professional and financial stakes are truly high.

Physician Credentialing Dispute Lawyers

Our Georgia-based business and healthcare law firm is focused on protecting and advancing the professional and financial interests of physicians and other healthcare professionals and providers.  Hamil Little maintains offices in Atlanta and Augusta, Georgia and provides legal representation and advice to physicians throughout the Southeast and beyond.  Our legal team has experience dealing with the nuanced legal and career ramifications that may attend problems with insurance and hospital credentialing.  A physician’s ability to obtain insurance or hospital credentialing might be impaired by various things, including, perceptions of clinical competence and judgment, medical malpractice history, prior disciplinary and collateral actions by state medical boards, alleged or perceived behavioral issues, or similar circumstances.  In many instances, the long-term impact of a credentialing denial can significantly exceed the immediate impact of the failed application for credentials.  Insurance provider agreements and hospital bylaws will reserve the right of the insurer or hospital to deny credentials to a healthcare professional based on concerns or evidence of the quality of care issues, clinical competence, professional misconduct, or behavioral problems.  The same documents will provide due process and related protections for the practitioner, through the legal process required to properly utilize such protections can be (and typically is) complex and esoteric.   Nevertheless, given the high stakes in play for the practitioner, the practitioner’s ability to properly protect her career interests through all available legal processes can become imperative.   Our law firm advises and represents physicians and other healthcare professionals in such matters.

For example, our firm advises and represents physicians and other healthcare professionals in the following types of credentialing related engagements:

  • Review and advice in preparing answers for credentialing questions
  • Professional Staff, Credentialing Committee and/or Medical Executive Committee interviews
  • Medical Executive Committee review, hearings, appeals or other hospital proceedings under hospital bylaws relating to credentialing
  • Insurance company appeals processes applicable to credentialing denials
  • Peer review and National Practitioner Data Bank (NPDB) reporting issues and appeals that impact or relate to physician credentialing
  • Credentialing related appeals
  • Judicial action and litigation to challenged unlawful credentialing denial, termination or other adverse processes that harms a physician
  • NPDB appeals and litigation relating to credentialing/peer review matters
  • Credentialing related proceedings before Administrative Law Judges
  • Medial and arbitration of credentialing disputes

Speak With One of Our Credentialing Healthcare Attorneys Today

A healthcare professional who finds herself in such circumstances should proceed cautiously due to the long-term career ramifications of such matters and preferably consult with her healthcare attorney.  Or, one of our healthcare attorneys will be happy to speak with you about whether our experience and services may be well suited to assist with your legal need.

Our healthcare law firm is AV-rated and has significant experience protecting healthcare professionals. Hamil Little has offices in Atlanta and Augusta, Georgia. Contact us at 404-685-1662 (Atlanta) or 706-722-7886 (Augusta) to schedule a confidential consultation.

DISCLAIMER: Any result this law firm or any lawyer of this law firm may achieve on behalf of one client in one matter does not necessarily indicate similar results can be obtained for other clients.