The Fight Against HMO and Insurance Company Terminations

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Nothing is more important to the viability of a medical practice than the relationships it enjoys with the patient population that relies on its excellent provision of health care. It is of paramount importance for optimal care that patients trust their physicians and are ensured long-term continuity of care. Of course, physician practices rely heavily on HMO and insurance companies to maintain physicians on practitioner panels and adequately reimburse services rendered. Therefore, when an HMO or insurance company terminates a physician from a panel, it can be devastating for patients and practices alike. Unfortunately, a determination by an HMO or other insurance company to terminate a physician often has nothing to do with the quality of care provided or what is in the patients’ best interests. Rather, these determinations are driven by large corporations looking out for their bottom line.

Why Do HMOs Terminate Physicians?

An HMO or other insurance company might terminate a physician for many reasons, including many that have nothing to do with patient care. These include:

  • Disputes over adequate reimbursement rates

  • An arbitrary determination by the HMO that there are too many physicians of a particular specialty in a certain geographic area

  • An arbitrary determination by the HMO that a physician billed incorrectly

As several corporate giants have come to dominate the health insurance industry in recent years, these HMOs have increasingly terminated physicians from the HMO panels and replaced the terminated practices with HMO-affiliated clinics. This has proven to be bad for physicians and worse for patients.

What Can Physicians Do?

Unfortunately, most provider agreements give the HMO or insurance company the right to terminate a physician without any stated reason and with little notice. To mitigate the chances of termination and the resulting damage to a medical practice, physicians are encouraged to do the following:

  • Take whatever legal measures are necessary to challenge a termination in the courts or through arbitration

  • Participate in a wide variety of insurance plans, so that long-term patients have other affordable options

  • Retain health care counsel and certified coders to regularly assess billing and coding practices to prevent insurance audits and disputes

  • Negotiate provider agreements to include provisions that prevent arbitrary terminations


©2021 Norris McLaughlin P.A., All Rights Reserved
National Law Review, Volume XI, Number 158



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