Physicians today are at the mercy of health insurers because if you do not have a contract as a “provider” with the insurer then you might very well lose a substantial portion of your income. I just recently had a case where a major insurer wrote to a surgeon and advised that the contract between the insurer and the surgeon was not going to be renewed when it expired in a few months. This situation was going to be an economic disaster for the physician because a large percentage of the surgeon’s work was being done on patients with this insurer. In fact, if this non-renewal actually went into effect it would very possibly have made it impossible for the surgeon to stay on the staff of the hospital where the surgeon operated.
So, what to do? First I looked carefully at the notification letter from the insurer and saw that there was an appeal process. We immediately filed an appeal and stated that the physician and I would both be participating in the appeal. The lesson is to read the letter and make absolutely certain that your appeal is timely.
I then saw that the reason for the non-renewal was due to a pending, New York State Department of Health, Office of Professional Medical Conduct (OPMC) investigation. I was involved in defending the physician in this OPMC matter and accordingly I was completely familiar with the facts.
In preparation for the appeal, I had the surgeon obtain a letter from the Chief of Surgery at the hospital which stated that my client was completely competent in all areas of surgical practice and was a valued member of the surgical staff. This letter was sent to the insurance company’s appeal panel. That panel, by the way, consisted of three physicians who worked for the insurance company but who had not participated at all with the decision to not renew my client’s contract with the insurer. You should be aware that you can produce any documents you want to support your case, and I strongly suggest you do so. For instance, you could submit medical literature to support your position or, as in my case, a letter from another senior physician who has first-hand knowledge regarding the competency of my client.
The appeal was done by a conference call which was set up by the company. The physicians on the appeal panel had in their possession a Statement of Charges against my client which had been posted on the OPMC website. The language in the Statement of Charges was very adverse to my client, as is usual, but we were prepared to fight these Charges. The appeals panel doctors asked my client to explain what happened in each case that was listed in the OPMC Charges. I had anticipated this situation and, therefore, I made certain that my client and I had gone over each and every detail of all of the matters so that the explanations we set forth were on point and we were able to back up those positions with facts. The second lesson to be learned is that you actually have to know what you are talking about if you want to succeed in this type of situation.
Also, I was able to bring the appeals panel up to date on the status of the OPMC matter. Unknown to the panel was that the Hearing that had been scheduled by OPMC in January of 2018 did not go forward and that the OPMC website now stated that the Charges had been withdrawn, without prejudice, and that OPMC had done nothing further with the case as of late September of this year. I was able to explain exactly what had happened and then I gave my opinion as to the weaknesses of the OPMC case against the surgeon.
The result was that I received a letter in a few days which stated that the appeals panel had reversed the non-renewal decision and that my client was again a provider in good standing. This decision truly avoided a great deal of potential difficulty for my client.
So, if you as a physician, or any type of health care provider, are being threatened with removal from the approved provider list of an insurance company, be aware that you must pay attention and go to work immediately to reverse the process. This means serving a timely notice of appeal, understanding what the issues are, obtaining and submitting documents that are favorable to you and, lastly, knowing 100% of the facts at issue so that you can effectively present your defense. In other words, be proactive to protect your interests, after all, it is your career that is in jeopardy.