Are You Facing a Credentialing Issue or Medical Privilege Dispute? Contact Us to Speak with a Georgia-Based Peer Review Attorney in Confidence

Our Georgia-based health law firm, with offices in Atlanta and Augusta, GA Georgia, advises and represents medical practices, physicians, and other healthcare providers in credentialing and peer review matters. We are a specialized, AV-rated boutique health law firm. Credentialing is an integral component of our modern healthcare system. Physicians and other licensed healthcare providers may need to go through the credentialing process with hospitals, insurance companies, government payers, and various other entities before they can see patients and bill for services rendered. With our exclusive focus on healthcare law, we are intimately familiar with all pertinent requirements, and a Georgia-based peer review attorney at our firm can guide you step-by-step through the process of obtaining—or protecting—the credentials or other privileges you need in order to practice.

Credentialing and Georgia-Based Peer Review Attorney

“Credentialing,” as that term is typically used in the healthcare industry, can refer to the medical credentialing process and the criteria applicable to, for example, a physician’s participation within a health plan or appointment to a hospital’s medical staff. The credentialing process is now an integral part of healthcare practice today as an important way to verify the qualifications of clinical practitioners. Credentialing practices and requirements vary somewhat by locale and practice setting, with nuances in law and process depending on the State. Although the details may vary according to the particular circumstances, the credentialing process typically involves a few steps, including:

Keeping updated contact information for all providers on staff;
Providing a checklist of information required of physicians in obtaining credentials at a practice site;
Planning ahead to perform a timely and detailed background check and verifying its accuracy with listed references, former employers, medical associations, federal agencies, and state boards;
Requiring peer references and checking them;
Investigating prior malpractice claims may suggest heightened scrutiny for providers with those issues.
Submitting the credentialing application to the practice site’s governing body for final review. For more information and additional steps, see https://www.beckersasc.com/asc-accreditation-and-patient-safety/10-steps-to-a-thorough-physician-credentialing-process.html

Some states, such as Georgia, through their medical boards and other cooperative hospital and healthcare associations, have developed standardized forms to facilitate efficient credentialing processes across disciplines. Although not required to participate, Georgia hospitals and health plans almost always accept the uniform application. See: https://www.georgiacredentialing.org/index.html

Common Issues During the Credentialing Process

While the credentialing process often goes smoothly, it is not uncommon for issues to arise. When this happens, physicians and other providers must work with experienced legal counsel to ensure that they resolve these issues as efficiently as possible and without any unnecessary adverse consequences. At Little Health Law, we have extensive experience resolving credentialing issues on behalf of our clients, both informally and through formal dispute resolution processes when necessary.

When preparing to go through a credentialing process, understanding any issues that are likely to arise can allow you to take proactive steps to avoid unnecessary disputes. A Georgia-based peer review attorney at our firm can assist you with this process and help you execute a strategy focused on avoiding unnecessary challenges if warranted. Our attorneys can assist you with resolving disputes during the credentialing process as well, and while we work with our clients to help them avoid these disputes whenever possible, we have significant experience guiding clients through dispute resolution proceedings as well.

Disputes that can arise impacting the credentialing and scope of practice of medical staff include:

Allegations that a physician has breached a contract or otherwise failed to follow medical staff by-laws
Negligent credentialing actions by a third party who asserts that a hospital or other practice site failed in its medical staff bylaws or peer review processes by allowing an unqualified physician to perform services
Physician disputes as to hospital decisions to deny medical privileges based on improper criteria (unrelated to quality of healthcare, treatment and services)

Georgia courts have held that although hospital bylaws, by themselves, do not constitute a contract between the hospital and the doctors, nevertheless, a hospital is bound by the bylaws it creates. If a hospital does not follow the procedures in its bylaws, a Court can require the hospital to follow those procedures. Robles v. Humana Hosp. Cartersville, 785 F.Supp. 989, 1001 (N.D. Ga. 1992), St. Mary’s Hosp., Inc. v. Radiology Prof’l Corp., 421 S.E.2d 731, 726 (Ga. Ct. App. 1992).

Our Medical Credentialing Services for Georgia Healthcare Providers

We provide comprehensive medical credentialing and peer review services for Georgia healthcare providers. Our attorneys provide representation throughout the credentialing lifecycle—from the initial application process through resolving disputes with public and private credentialing authorities. If you need help with any of the following, we encourage you to schedule an appointment with a Georgia-based peer review attorney at our offices in Atlanta or Augusta:

Navigating the Credentialing Process with Hospitals and Insurance Companies

Our attorneys regularly assist clients with navigating the credentialing process with hospitals and private insurance companies. Whether a hospital or health plan accepts the uniform credentialing application or requires compliance with its own unique set of requirements and procedures, we can help providers work through the process and submit all information required to secure their desired credentials. We routinely assist with steps such as:

Conducting pre-filing eligibility and risk assessments
Preparing and filing credentialing applications
Managing the credentialing application process
Responding to requests for additional information
Corresponding with credentialing personnel

In many cases, the credentialing process can take months, and providers will need to take a proactive approach to ensure that the process goes as smoothly and quickly as possible. We do this on behalf of our clients, following up regularly and ensuring that our clients have all of the information they need to respond to inquiries and additional documentation requests appropriately. We also help our clients proactively address any issues that arise during the credentialing process—as these issues can potentially lead to problems in other areas if not resolved favorably.

Navigating the Credentialing Process with Medicare, Medicaid, and Other Public Payers

In addition to handling credentialing matters with hospitals and private insurers, we also handle credentialing matters with Medicare, Medicaid, and other public payers. Just like private insurers, the Centers for Medicare and Medicaid Services (CMS) and other governmental authorities take steps to ensure that the individuals and organizations they authorize to bill for medical services are qualified to do so.

While CMS provides enrollment guides for healthcare providers, these guides are difficult to follow, and they do not tell providers everything they need to know. As a result, it is essential to work with experienced legal counsel throughout the process. We assist all types of providers with Medicare and Medicaid credentialing, including (but not limited to):

Physicians and other licensed healthcare providers
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers
Hospitals
Critical care facilities
Skilled nursing facilities
Home health agencies
Hospices and other institutions

Along with managing the initial enrollment process, we assist providers with maintaining their Medicare and Medicaid credentials as well. From implementing compliance policies and procedures to applying for revalidation and from managing Medicare Administrative Contractor (MAC) audits to providing representation for federal healthcare billing fraud investigations, we have extensive experience assisting with all aspects of ensuring that our clients are able to bill the government.

Establishing Policies and Procedures to Maintain Compliance with Credentialing Requirements

Credentialing is not a one-time event. Once a provider obtains credentials from a hospital, insurance company, or government payer, the provider must implement proactive measures to ensure compliance and maintain its credentials going forward.

This starts with establishing and implementing effective policies and procedures. For a provider’s policies and procedures to serve their intended purpose, they must be custom-tailored to the provider’s specific risks and needs. With this in mind, we work closely with our clients throughout the drafting process. By understanding the unique aspects of our clients’ practices and businesses, we are able to clearly identify their specific risks and needs, and then we are able to use this information to craft policies and procedures that they can use to effectively manage compliance on an ongoing basis.

Managing and Documenting Compliance on an Ongoing Basis

We assist many of our clients with managing compliance on an ongoing basis as well. When it comes to managing compliance for credentialing purposes, it is critical not only to maintain compliance but also to maintain documentation of compliance. At the time of renewal, or in the event of an audit or other inquiry, having documentation on hand that clearly demonstrates compliance can significantly reduce the risk of a dispute that threatens a provider’s practice or business.

Resolving Credentialing Disputes with Hospitals, Insurance Companies, Public Payers and Other Entities

When necessary, we also help our clients resolve credentialing disputes with hospitals, insurance companies, public payers, and other entities. In many cases, we are able to resolve these disputes informally and confidentially—and this is generally the most efficient and most favorable approach. However, sometimes, disputes regarding eligibility, compliance, and other issues can lead to litigation and formal dispute resolution proceedings. With our attorneys’ vast experience representing healthcare providers, we are intimately familiar with the processes and procedures involved, and we are able to take a forceful, strategic, and cost-effective approach to protecting our clients’ interests.

Experienced Legal Counsel for Medical Privilege Disputes in Georgia

We also represent physicians and other licensed healthcare providers in medical privilege disputes in Georgia. These disputes can arise in various circumstances, and they can involve a wide range of issues. When facing a medical privilege dispute, understanding the specific issue (or issues) involved is critical, as this will allow you to identify both the scope of your risk and the defenses you have available.

Some examples of common issues in medical privilege disputes include:

Accusations of Criminal Conduct – Facing criminal accusations can lead to the loss of medical privileges in many cases. This includes accusations of healthcare fraud, driving under the influence (DUI), illegal drug use, and other crimes.
Accusations of Medical Negligence or Malpractice – Accusations of medical negligence or malpractice can trigger medical privilege disputes as well. As with criminal allegations, accusations of negligence or malpractice are not themselves evidence of wrongdoing, and licensed practitioners will have viable defenses in many cases.
Accusations of Professional Misconduct – Along with medical negligence and malpractice, other forms of professional misconduct can lead to medical privilege disputes as well. Allegations in these cases can range from failing to maintain patient confidentiality to engaging in harassment or discriminatory conduct.
Loss of Credentials – Losing credentials with a hospital or other entity can also trigger efforts to revoke a licensed provider’s medical privileges. If you are facing a credentialing issue, we can work to protect your credentials and privileges by all available means.
Substance Abuse – Allegations of substance abuse are a common trigger for medical privilege disputes as well. This includes allegations of abusing alcohol, marijuana, prescription medications, and other drugs. Regardless of the veracity of these allegations, you have options available, and a Georgia-based peer review attorney at our firm can help you take all of the necessary steps to protect your privileges, your license, and your medical career.

If you are at risk of losing your medical privileges, we strongly encourage you to speak with a Georgia-based peer review attorney at our firm as soon as possible. In these cases, time can be of the essence, and allegations that trigger privilege disputes have the potential to trigger professional licensing action and other proceedings as well. As a result, an informed and strategic approach is required, and engaging experienced counsel is the first step toward protecting your ability to practice.

Speak with a Georgia-Based Peer Review Attorney at Little Health Law in Confidence

Our Georgia-based health law firm is focused exclusively on representing physicians, medical practices, and other healthcare providers and practitioners. To schedule a confidential consultation, email us at info@littlehealthlaw.com.

Credentialing and Medical Privilege Disputes