Medicare, Medicaid, & Insurance Exclusions

A physician subject to a restriction, suspension or limitation on a medical license (as well as certain criminal convictions) often triggers a termination from Medicare, Medicaid and insurance company networks. A physician excluded from an insurance provider network, or government program such as Medicaid, has a right to appeal the exclusion. Appealing the exclusion or termination can be critical to a doctor maintaining his or her medical practice. Aside from lost income, most hospital bylaws mandate suspension or revocation of hospital privileges upon termination from Medicate, Medicaid or any other government related health program.

Some grounds for exclusion from government health programs, such as Medicaid, are mandatory and require the termination to remain effective for years. Other grounds that give rise to an exclusion are not mandatory, but within the discretion of the provider. It is important to retain an attorney who can determine whether your exclusion is mandatory or permissive and who knows the laws and regulations pertaining to such appeals. Elder & Good medical license defense attorneys have successfully appealed terminations imposed by private insurance networks and terminations imposed by government health programs, such as Medicaid and Medicare. In some instances, physicians have been reinstated after we submitted written appeals. In other instances, physicians have been reinstated after we met with representatives of the provider or conducted telephonic or live hearings.

We have represented physicians through every step of the administrative appeals process in defending against an exclusion from Medicaid. This process includes filing written submissions, attending dispute resolution meetings in Frankfort at the offices of the Cabinet for Health and Family Services, and engaging in formal hearings before a hearing officer. We have also appealed Medicaid exclusions to a court of law, resulting in reversal of the exclusion and reinstatement of a provider agreement. In addition, we have assisted nurses obtain reinstatement as Medicaid providers after a termination based on a criminal conviction or Nursing Board action.

It is important to note that strong legal representation through the investigation and disciplinary stages of a Medical Board or Nursing Board case can result in the complete dismissal of a grievance, or alternatively, in orders or agreements that impose no restrictions on a professional license. These favorable outcomes usually will not trigger an exclusion from Medicare, Medicaid or other provider networks. Moreover, strong legal representation from the outset of an investigation can result in informal Board action, such as a diversion agreement or letter of concern. These informal resolutions are confidential, not reported to the National Practitioner Data Bank and not subject to scrutiny by Medicare, Medicaid and insurance companies.

Additionally, it is important to consult with an attorney who is aware of the impact a criminal conviction can have upon a health care professional’s participation in Medicare, Medicaid and other insurance plans. Some criminal convictions can result in a five year mandatory exclusion from Medicare, Medicaid and other federally funded programs. Criminal convictions (or termination from federal health programs for any reason) may make a doctor or nurse ineligible to obtain employment with any health care organization receiving federal funding. Chad Elder and Brian Good have the experience and knowledge to provide comprehensive representation during the criminal and licensing processes to obtain the best possible result on all fronts.

In short, it is imperative to retain strong, experienced and effective attorneys on the front end of a Board case or criminal investigation in order to dramatically increase the chances of avoiding unexpected and undesirable results on the back end. Contact Chad Elder and Brian Good for effective and experienced representation.