Licensing, Certification, Staff Privileges, and Credentialing

Licensing and Disciplinary Matters

State licensing board investigations, patient complaints or complaints from other health care providers can lead to licensing investigations with disciplinary consequences. Although licensing investigations may be quickly closed when the complaint has no merit, it is best practice that providers have counsel present when speaking with investigators.

 

Staff Privileges and Peer-Review

Many physicians and providers rely on hospital affiliations and privileges for provision of healthcare services to their patients.  Revocation of or limitations on privileges could be reportable to the NPDB, which makes it more difficult to obtain future credentialing at a hospital or health insurance carrier, find employment or certify/recertify with certification boards.

We represent providers who are subject to peer-review processes, at risk of being terminated from medical staffs or are being denied medical staff membership.  We guide providers through initial peer-review and the subsequent appeals or fair hearing processes.

 

Credentialing with Payor Networks

Loss of credentialing from a payor network can have financial and professional consequences for providers.  For example, termination of payor credentialing may be reportable to NPDB.  We represent providers in obtaining credentialing or maintaining credentials in provider networks, such as HMOs, Medicare or Medicaid. 

 

Board Certification

Obtaining and maintaining board certification in a medical specialty is important in and at times pertinent to the practice of medicine.  Board certification may be necessary in credentialing with health plans and hospitals, and required for employment.  Desertification may also lead to reporting to the NPDB.  We represent and defend physicians before national certification boards and for certification issues. 

 

Medicare Enrollment

Appealing Medicare enrollment matters and revocation of provider number can become complicated and time consuming.  We represent providers in appealing enrollment and provider number revocation matters.  We also represent providers who have been provided inappropriate effective billing dates for enrollment and help providers and suppliers with revalidation requests to appropriately complete the revalidation application.