California law specifically protects physicians and other health care providers who advocate for patient care from any kind of retaliation by health plans, insurers or medical groups.
California Business & Professions Code §510 and §2056 state that it is unlawful to terminate employment or any contractual relationship, or penalize, or retaliate against, physicians and providers who “advocate for medically appropriate health care for their patients”. Advocacy includes:
Appealing a decision to deny payment
Protesting or complaining or refusing to follow or comply with any decision or policy or practice that impairs the providers’ ability to provide health care to patients
What is retaliation?
Here are some examples of retaliation:
Health plan A. will not authorize a test, procedure or treatment ordered by Dr. Jones. Jones appeals the denial by calling or writing to the health plan. Despite having no prior issues, Dr. Jones is placed on “special claims review” (or audit). That review/audit is punitive because it requires Dr. Jones’ office to submit copies of medical records when it bills the health plan, which in turn delays and/or results in denied payments.
Smith orders certain medications that are not on Insurer B.’s formulary, which means that Insurer B. will not pay for them. Dr. Smith does not appeal the denied payments but continues to order the medications after the patient is told the insurer may not pay. Dr. Smith thereafter receives a notice from Insurer B. stating that his/her “Participating Provider Agreement” is “not being renewed”.
Brown, after years of employment, is told by Medical Group C. that his/her employment is being terminated without cause. Dr. Brown has the highest patient satisfaction scores in the medical group but doesn’t always meet his RVU (“productivity”) quotas.
The list of examples could go on and on. If you think you may be a victim of health plan, insurer or medical group retaliation, contact an experienced health care law attorney.