Healthcare Licensing, Staff Privileging, Credentialing Lawyer
Medicare Enrollment and Revalidation
For the past 25 years, our attorneys have counseled healthcare provider clients and represented them with regard to sensitive licensure, medical staff privilege, and credentialing matters. We have represented all types of providers, including physicians, dentists, podiatrists, chiropractors, nurses and other healthcare providers. We use our experience and relationships to address matters in creative and non-adversarial ways when possible.
State licensure, medical staff privileging and credentialing matters can have numerous impacts on providers and their businesses, such as reports to state and national databanks, additional actions by other states, termination of staff privileges and other relationships, as well as third party payor de-participation. Due to the domino effect that often accompanies sanctions or settlements of licensing or privileging matters, it is very important to retain experienced healthcare counsel who can assess the collateral damage that could result. Our attorneys understand the potential consequences and will strive to settle matters in a manner that results in the least possible collateral effects.
Licensure investigations can arise from a variety of sources, such as patient complaints or complaints from other health care providers. Sometimes investigations are closed quite quickly when the complaint has no merit. Even when complaints seem to have no merit, we always recommend that providers always have counsel present when speaking with investigators.
Central to many physicians' practices are their hospital affiliations and privileges. Without these hospital privileges, physicians may be hard pressed to get referrals or patients. Further, if a provider loses privileges at a hospital, or has those privileges limited in any way, it could be reportable to the NPDB, which makes it even more difficult to obtain credentialing at a hospital or find employment in the future.
Our attorneys frequently represent physicians who are at risk of being terminated from medical staffs or are being denied membership. Our attorneys guide physicians through the formal appeals process and represent providers during the fair hearing process if applicable. We can also evaluate the feasibility of litigation and represent providers if litigation is recommended.
Many clients come to us because of difficulties with getting credentialed or maintaining credentials in HMOs, PPOs or other similar provider networks. Disaffiliation from a payor network can have financial consequences as well as a stigma attached. We have successfully represented many providers with regard to maintaining credentials in various payor networks.
In the current landscape of the medical profession, certification by a physician's applicable medical specialty board has become a place holder for the competence of that physician. Without board certification in a specialty, a provider may have trouble credentialing with health plans and hospitals, and may have difficulty finding employment. The loss of board certification can also lead to reporting to the NPDB. Our firm was recently retained by a large group of physicians whose specialty certification status was threatened by the specialty board.
Providers who are having difficulty enrolling in Medicare or who have had their provider number revoked often seek our assistance when navigating the enrollment process or appealing decisions to revoke. We have also successfully represented providers who have been given inappropriate effective billing dates for enrollment. We frequently help providers and suppliers who have received revalidation requests to appropriately complete the revalidation application.
What is the Process for Health Care Professional Licensure Investigations in the State of Michigan?
Providers generally become aware of licensing issues when they are contacted by an investigator from the Michigan Department of Licensing and Regulatory Affairs (LARA), Bureau of Health Professions (BHP). The BHP is generally notified of a complaint against the provider either by a patient or by the provider's employer. The BHP investigator will normally attempt to take a statement from every party that could have information about the complaint, including the provider, in order to determine whether the provider has violated the Michigan Public Health Code. The provider's opportunity to meet with the investigator is a very important one, as it is the only opportunity a provider will have to tell his or her "side of the story" before the investigator makes a recommendation to his or her superior whether or not to pursue the complaint further.
We highly recommend that any provider contacted by a BHP investigator immediately contact competent legal counsel, even if the provider knows that the complaint allegations are frivolous or unfounded. Retaining legal counsel at an early stage, especially before a BHP investigator recommends pursuing an administrative complaint, is essential in defending a professional licensure complaint. The effects of an adverse action taken by the State Michigan against a provider, including the possibility of reporting to the National Practitioner Databank (NPDB), mean that is imperative that healthcare providers retain counsel as early as possible in a licensure case.
If the investigator does decide to recommend to his or her superiors that the case proceed, the file will be sent to the Michigan Attorney General's (AG) office where a decision will be made whether the AG's office believes the provider violated the Public Health Code, and thus whether to file an administrative complaint against the provider. If the AG's office does decide to file a formal administrative complaint, the provider will receive a copy of it and be asked to respond within 30 days.
After the provider, usually with the assistance of legal counsel, answers the state's administrative complaint, the next step is for the provider and his or her counsel to attend a compliance conference with members of the AG's office and members of the BHP. At this meeting, the provider will be expected to explain whether and how he or she has not violated, or complied with, the Public Health Code. This stage presents an opportunity to settle the case with the State of Michigan.
If the provider and counsel are unable to settle the case after the compliance conference, the matter proceeds to a hearing before an Administrative Law Judge (ALJ). This hearing is very similar to a court proceeding and both sides, the provider and the AG's office, will present their cases: calling witness, presenting evidence, etc. Obviously, at this point a competent healthcare attorney is a necessity in order to effectively argue the provider's case before the ALJ.
Based upon the evidence at hearing the ALJ will make a ruling that serves as a recommendation for the BHP's relevant board (medicine, dental, nursing, pharmacy, etc.). The Board will meet and decide whether to adopt the ALJ's recommendation and, if the ALJ rules that the provider has violated the Public Health Code, whether to discipline the provider for this violation.
If, at any point in this process after the AG's office files an administrative complaint, the BHP imposes discipline upon the provider, there is significant risk that the BHP will be required to report the adverse action to the NPDB, which serves as a kind of "permanent record" for providers, accessible to employers, payors and the government. This adverse action will stay on the NPDB's record for a substantial amount of time, and can result in a provider being unable to be credentialed for employers and payors, and cause the provider even more stress and cost trying to fight the NPDB report.
What is the Process for Appealing a Medical Staff Determiation?
Many times, a provider will learn about an investigation by the Medical Executive Committee (MEC) of a hospital, or a similarly named oversight committee and attempt to defend him or herself against allegations of, for example, sub-par patient care, or substance diversion.
Normally, hospitals' fair hearing procedures allow a hearing before the MEC, or its designated panel, and explicitly allow a provider to be represented by counsel. These procedures allow usually allow for the calling of witness and the presentation of evidence. If the MEC rules against a physician, the physician is generally allowed at least one level of appeal within the hospital system.
The National Practitioner Databank
Information for Licensing of Health Care Professionals in Michigan