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  • Theresa Barta

When Insurers Retaliate Against Physicians, They Also Harm Patients

When insurers, health plans and health care systems retaliate against physicians, surgeons, and other health care providers (which is unlawful), it harms not only the physician, but also patients.

Retaliation against physicians can take many forms. For example, denied or down-coded claims, denied pre-authorizations, placing the physician on audit or special/pre-payment review, not listing the physician on the insurers/health plan’s provider directory, terminating physicians in-network status and not paying for services performed by out-of-network providers.

Although insurers, health plans and health care systems claim to exist for their members (i.e., patients) with the purpose of providing health care, their retaliatory conduct against physicians actually harms patients, and the insurers, health plans and health care systems know it. Thus, under California law, such retaliatory conduct constitutes “willful and conscious disregard of the rights of patients” which justifies punitive damages.


Denied And Down-Coded Claims

When physician’s claims for payment for the medical services they have provided are denied or down-coded by insurers, health plans and health care systems, it is the patient who ends of paying (maybe not for everything, but it definitely comes out of their pocket).


Regardless of whether the insurer, health plan or health care system calls itself “non-profit”, they all operate as for-profit companies, meaning that profits motivate their actions. Their business model is: premiums (revenue) minus payments for medical care and costs = income (profits). Thus, when insurers, health plans and health plan systems (who have collected premiums) do not pay claims (because they are retaliating against a physician by denying or down-coding their claims), the patient is harmed as well as the physician.


Pre-Payment Or Special Claims Reviews

When the retaliatory conduct is placing a physician on “pre-payment or special claims review,” patients are harmed because the process delays and typically results in denied payments of claims (leaving the patient with the bill).


Terminating Or Removing Physicians From Provider Directories

When a physician is terminated or their name removed from the insurers, health plans or health systems’ provider directories, patients are led to believe that the physician is “out of network.” Since many health plans will not pay for services rendered by an out-of-network provider (or pay less), patients typically look to receive their medical care from only in-network providers. When a patient’s physician is not listed in the provider directory (and the physician is actually in-network), the patient is misled into seeking care for another doctor.


So, when physicians are retaliated against by insurers, health plans and health care systems, they are not the only ones who are harmed. Their patients are harmed as well.

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