Insurers often violate law when terminating Medicare Advantage plan doctors
Updated: Oct 8
Are you a doctor who provides services to patients through Medicare Advantage plans?
IF SO . . . you should know that a federal law (CFR § 422.202) requires that before you can be terminated from a Medicare Advantage plan, the insurer or health plan must do each of the following:
1. Provide you with written notice.
2. Tell you why you are being terminated. If the reason is because of profiling, the insurer must provide you with the profiling data they used as well as the number and types of other physicians in the plan.
3. The notice must also state that you have the right to appeal and explain the process and timing for requesting a hearing.
In most of the cases I handle as an attorney representing health care professionals, insurers simply ignore the law – so don’t expect that they will follow it in your case. Seek legal advice if you have been terminated.
As insurers continue to use narrow networks, they will continue to terminate physicians using a number of illegal practices – e.g., claiming the termination is without cause, providing a reason that is pretextual, for example claiming there is no network need in certain geographic areas or medical specialties, or falsely claiming the physician breached their contract.
There are many laws that protect doctors from such unlawful conduct, which in turn also protect patients who would otherwise lose their doctor when the doctor is suddenly dropped from provider networks. Physicians need to protect themselves and their patients.
An Important Note: If you’re terminated, find out whether your contract provides for services to Medicare Advantage patients. It may not be readily apparent because of silent networks.