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Gerald, Esq
Gerald, Esq, Lawyer
Category: Legal
Satisfied Customers: 2880
Experience:  30 years of experience
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Can a physician in good standing be legally banned from a

Customer Question

Can a physician in good standing be legally banned from a medical insurance company as a provider?
JA: What state are you in? It matters because laws vary by location.
Customer: Indiana and California
JA: Has anything been filed or reported?
Customer: United Health Care has refused to recredential my husband because during the course of his twenty year career he settled four lawsuits four of which occurred fifteen years ago in Pennsylvania.
JA: Anything else you want the lawyer to know before I connect you?
Customer: His removal from the network was based on a more recent case in Indiana where he was not the primary physician but was named in the suit.
Submitted: 1 month ago.
Category: Legal
Expert:  Gerald, Esq replied 1 month ago.

Hello,
Thank you for using Just Answer. Please bear with me while I review your question. I will respond fully shortly. Thank you for your patience.

Expert:  Gerald, Esq replied 1 month ago.

Hello,

Thank you for your patience and thank you for using Just Answer. I want to provide you the best service I can. Please feel free to ask any follow up questions you have.

I am an attorney with 30 years of experience including extensive experience in the regulation of health care professionals. I hope to provide you information that will help you in resolving your question.

Unfortunately the insurance companies do have fairly broad discretion in regard to accepting physicians (and other professionals) into their network. They do not rely simply on the licensing Board's determination (or even the specialty board certification) as to whom they will accept.

This does NOT mean that your husband is without remedy. There are two steps that he can (and should pursue):

1) All insurance companies are required to have an internal appeal process through which a professional can appeal the determination of the insurer not to include them in the network.

2) If he is unsuccessful in the internal appeal he can sue the insurance company for "Restraint of Trade."

In either of these instances the process can be a little complicated. I know that your husband must be very intelligent to have become a physician. I worked very closely with physicians for many years and most of them believe they can be their own attorneys. Usually, it doesn't work out as well for them than if they retained a health care law attorney with experience fighting these credentialing issues.

The state medical society is a good place to get a referral to such attorneys.

If you Google: "California medical credential attorneys"

you will find some as well.

I hope the information I provide is useful to you. I want you to be comfortable and satisfied with my attempt to assist you. Please, if you have ANY follow up questions, feel free to ask. Please note that I am generally unavailable Friday evening through Sunday.

Please do not forget to give me a positive rating. It adds nothing to your costs but it helps me greatly. Thank you.

If you are dissatisfied with my response PLEASE let me know before giving me a negative review so that I may try to be of better assistance. Or if you prefer, let me know and I can “Opt Out” and your question can be re-posted without additional cost to you. I will be fair to you and only ask the same from you.

Good luck.

Please note: Information is educational and not given as legal advice. Only your local attorney can give legal advice. I can't establish or accept an attorney-client relationship with you. All posts are available for public viewing.

Kind regards,

Gerald

Expert:  Gerald, Esq replied 1 month ago.

I hope I did not sound flip in regard to your husband. That is NOT my intention. I just want him to have the best chance at getting this turned around in his favor.

Kind regards,

Gerald