Medicare, Medicaid, & Insurance Exclusions

Medicare, Medicaid and Insurance Exclusions

A physician subject to a restriction, suspension or any limitation on a medical license can trigger termination from Medicare, Medicaid and private insurance company networks. A physician excluded from an insurance provider network, or a government program such as Medicaid, Medicare or Passport has the right to appeal the exclusion. Appealing the exclusion or termination can be critical to a physician maintaining his or her medical practice in Kentucky or Ohio. Aside from lost income, most hospital bylaws mandate suspension or revocation of hospital privileges upon termination from Medicare, Medicaid or any other government or private health program.

Some grounds for exclusion from government health programs, such as Medicaid or Medicare, 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 and professional license defense attorneys have successfully appealed terminations imposed by Medicaid, Medicare and private insurance networks. In some instances, physicians have been reinstated after our lawyers submitted written appeals. In other instances, physicians have been reinstated after we have met with representatives of the provider or conducted telephonic or live hearings.

Our medical and professional license defense attorneys have represented physicians through every step of the administrative appeals process in defending against an exclusion from Kentucky Medicaid. This process includes filing written submissions to Kentucky Medicaid, attending dispute resolution meetings in Frankfort at the offices of the Cabinet for Health and Family Services, and engaging in a formal hearing before a hearing officer.

Our medical and professional license defense attorneys have also appealed Kentucky 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 discipline by the Kentucky Board of Nursing.

It is important to stress that retaining an effective medical license defense attorney to defend a medical license before the Kentucky or Ohio Medical Board can result in the complete dismissal of a complaint, or alternatively, in orders or agreements that impose no restrictions on a Kentucky or Ohio medical license. These favorable outcomes usually will not trigger an exclusion from Medicare, Medicaid or private insurance networks. Moreover, retaining an experienced medical license defense attorney at the outset of an investigation by the Kentucky or Ohio Medical Board can result in informal Board action, such as a letter of concern or diversion agreement. Letters of concerns and diversion agreements are confidential, not discipline, not reported to the National Practitioner Data Bank and not subject to scrutiny by Medicare, Medicaid and private insurance companies.

Additionally, it is important to consult with an attorney who understands the impact a criminal conviction may have upon a physician’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) can result in a physician, nurse or other health care professional ineligible to obtain employment with any employer receiving federal funding. Our medical and professional license defense attorneys are well equipped to provide comprehensive representation in Kentucky and Ohio during criminal proceedings and medical Board cases to maximize the best possible result on all fronts.

In short, it is imperative to retain strong, experienced and effective medical and professional license defense attorneys on the front end of a Kentucky or Ohio Medical Board, nursing board or criminal matter. Doing so will dramatically increase the chances of avoiding unexpected and undesirable results on the back end. Contact our Kentucky and Ohio medical and professional license defense attorneys for effective representation.