Medicare - Compliance, Termination & Appeals
Termination & Appeals (Practitioners & HDOs)
Pursuant to applicable law and the applicable provisions of its practitioner contracts, ConnectiCare has the right to suspend, restrict, or terminate practitioners whose conduct adversely affects or could adversely affect the health or welfare of a member or members, who fail to remain in compliance with ConnectiCare’s credentialing criteria, who lose privileges with an institutional provider, who have sanctions or restrictions imposed upon licensure; or who have been arrested, convicted, indicted, or charged with any felony charge related to moral turpitude or the practice of medicine. Under no circumstances will ConnectiCare initiate termination actions against a practitioner/provider solely because he or she has:
• advocated on behalf of a member
• filed a complaint against ConnectiCare with state/federal regulatory bodies
• appealed a preferred health plan decision
• provided information to an appropriate agency
• requested a hearing or review
Practitioners have the right to appeal ConnectiCare’s decision to take adverse action against them “for cause” in accordance with the Health Care Quality Improvement Act of 1986. ConnectiCare reserves its right to terminate a practitioner’s participation without cause if permitted by practitioner contract and applicable law, where there is no quality-related reason for the termination. Practitioners terminated pursuant to the “without cause” provision in their contract have no right to appeal such termination.
1. Should ConnectiCare make the decision to reduce, suspend or terminate a practitioner’s participation “for cause,” ConnectiCare shall provide written notice to the practitioner stating:
• that disciplinary action has been proposed against the practitioner;
• the reasons for the proposed action;
• that the practitioner has the right to request a hearing on the proposed action;
• that the practitioner has thirty (30) business days from the date of the notice within which to request such a hearing; and
• a summary of the practitioner’s rights in the hearing.
2. If a hearing is requested on a timely basis by a practitioner who receives a notice, within ten (10) business days of its receipt of the practitioner’s request for a hearing, ConnectiCare shall send to the practitioner a notice providing:
• the place, time and date of the hearing, which shall be no more than sixty (60), but not less than thirty (30), business days after the date of the notice; and
• a list of witnesses (if any) expected to testify at the hearing on behalf of ConnectiCare.
3. The appeals hearing shall be held before a subcommittee of ConnectiCare’s Quality Improvement Committee (QIC). The subcommittee shall consist of three practitioners who are not in direct economic competition with the practitioner involved.
4. The right to an appeals hearing may be forfeited if the practitioner fails, without good cause, to appear. The practitioner may designate a representative in writing with full authority of himself/herself or through an authorized representative.
5. At the appeals hearing, the practitioner has the right:
• to representation by an attorney or other person of the practitioner’s choice;
• to have a record made of the proceedings, copies of which may be obtained by the practitioner upon payment of any reasonable charges associated with the preparation thereof;
• to present evidence determined to be relevant by the subcommittee, regardless of its admissibility in a court of law; and
• to submit a written statement at the close of the hearing.
6. Within ten (10) business days of the completion of the appeals hearing, the subcommittee shall render its decision. The QIC’s decision shall be final. The decision, along with the basis of its decision, shall be communicated in writing to the practitioner within five (5) business days of its having reached such decision.
7. In accordance with the requirements of applicable federal and state law, ConnectiCare shall notify the appropriate regulatory authority of any final decision of the QIC to reduce, suspend or terminate a practitioner’s participation for quality-related reasons.