Texas Defense Attorneys

Physician Peer Review and Credentialing Defense Attorneys

Peer review and credentialing actions can pose a significant threat to a physician’s career. If not handled appropriately, such actions can lead to a permanent adverse report with the National Practitioner Data Bank and possible disciplinary action by the Medical Board. If you are facing a possible peer review or credentialing action, it is vital to consult an experienced attorney early on. The longer the delay, the more likely it becomes that your case could lead to a bad or subpar outcome.

The attorneys at Lype, Dest & Smith Lawyers have decades of experience successfully defending physicians and other practitioners in peer review and credentialing actions. We work closely with our clients to develop an individualized strategy based on the facts of their case, their goals, and the stance of the credentialing entity. Our attorneys know how to navigate the complexities of the peer review process and National Practitioner Data Bank reporting requirements.

The Basics of Peer Review

Physicians are generally required to be members of a facility’s medical staff in order to treat or admit patients to that particular hospital or facility. This is also referred to as having privileges at a hospital. As a member of the hospital’s medical staff, the physician is subject to the hospital’s bylaws and certain requirements to remain in good standing with the hospital. The peer review process is intended to improve patient safety and quality of care. Generally, a peer review proceeding is instituted in situations where the physician has allegedly violated the hospital bylaws or policies by failing to maintain the standard of care, acting in a disruptive manner, or being physically or mentally impaired. The determination of whether any of those allegations are valid and what sort of action to take against the physician’s medical staff privileges is made by a peer review committee of the physician’s peers.

The actions that can be taken against a physician’s medical staff privileges can include revocation, suspension, or restriction, and can obviously have a major impact on a physician’s ability to practice in that hospital. Adverse actions taken by the hospital peer review committee can also result in adverse actions by other hospitals, insurance panels, and the Texas Medical Board. In sum, a negative peer review result can have potentially devastating effects on a physician’s practice well beyond one particular hospital.

Peer review proceedings are governed by State and Federal (Health Care Quality Improvement Act) statutes and further procedural processes are often codified in the hospital’s bylaws. The statutes governing the peer review process can be confusing and are often complicated by the hospital failing to follow their own bylaws. A good understanding of the peer review process and experienced legal guidance are of paramount importance in dealing with a hospital peer review.

Informal Peer Review Proceedings

Certain issues can often be resolved informally between the physician and the peer review committee without a formal investigation and public National Practitioner Data Bank report. Informal resolution may be appropriate in situations where the conduct is not terribly serious and/or the intervention is early. For example, a physician who has had difficulty finalizing their operative notes in a timely fashion, as required by hospital bylaws, may be counseled or placed on a performance improvement plan in order to bring them back into compliance. Ideally, the physician is able to address the issue(s) and, while record of the remediation may go in their staff file, there is no public action to speak of.

Darrin Dest

Darrin’s practices primarily in the areas of administrative and health care law, with a focus on the representation of professionals in front of their licensing boards and credentialing bodies. Darrin formerly worked for the Texas Medical Board and currently defends licensees.

Years of experience: 15 years
Bar numbers: 24065146
Location: Austin, TX

Peer Review Investigation

A formal peer review investigation is usually prompted by a sentinel event, whether it is a poor patient outcome, an instance of disruptive conduct, or evidence of impairment. Depending on the seriousness of the issue and/or the likelihood that it could adversely affects patient care, the hospital peer review committee will first decide whether it warrants summary suspension of the physician’s medical privileges while the investigation is ongoing. Generally, the physician is notified of the Peer Review Investigation via a certified letter containing a description of the allegations. For standard of care concerns, the medical records at issue are often sent to an external source for an outside review. The physician may be asked to meet with the committee or provide a written explanation, but often the peer review proceeding will advance with little input from the subject physician.

Once the committee has reviewed the investigation materials and outside expert review, if applicable, they will make a recommendation. If the recommendation would adversely affect the physician’s privileges through modification, restriction, or revocation, the physician will be informed of their rights to a Fair Hearing. In most instances, Texas law also gives physicians the ability to request a mediation to attempt resolution of the matter without the need for the Fair Hearing.

Fair Hearing

If the physician disputes the committee’s recommendation, they can request a Fair Hearing. The Fair Hearing is conducted by the hospital before a panel of physicians selected from the medical staff. Like the rest of the peer review proceedings, the Federal (HCQIA) and State laws provide several rights to the physician throughout the proceedings, including the right to be represented by an attorney, the right to call witnesses, and the right to present evidence. At the end of the hearing, the Panel will deliberate and communicate their recommendation to the physician. Often, the decision is then subject to approval by the hospital’s governing board. Once final, if the recommendation adversely affects the physician’s privileges, it will be reported to the National Practitioner Data Bank and subsequently communicated to other credentialing entities.

 

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Dan Lype

Founding Attorney

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Your license to practice medicine is your livelihood and reputation. Do not take a hospital peer review or the possibility of a hospital peer review lightly. Avail yourself of confident and experienced legal counsel as early in the process as you can. The attorneys at Lype, Dest & Smith are highly experienced defending physicians in hospital peer review proceedings and are available for consultation.

Representative Cases

The following are examples of some of the peer review cases that have been defended by our attorneys:

• MD v. Hospital

A neurosurgeon was accused of falling below the standard of care during several procedures. The head of client’s neurosurgery group threatened to initiate peer review action against client. Early legal intervention led to a clean exit from the hospital and client’s neurosurgery group without the filing of a Data Bank report of Medical Board complaint. The separation agreement also awarded the pay and benefits they would have received had they finished their contract.

• MD v. Hospital

Anesthesiologist had several bad outcomes in cases that allegedly fell below the standard of care. Peer review action was initiated with the client also being terminated by their anesthesia group under an administrative provision in their employment contract. Our attorneys successfully convinced the hospital that under their bylaws, the client’s privileges were automatically voided when their anesthesia group terminated his contract. This meant peer review was moot and the voiding of the client’s privileges was not reportable to the National Practitioner Data Bank or the Medical Board.

• MD v. Hospital

A surgeon’s privileges were partially suspended following a procedure that allegedly fell below the standard of care. The client did not hire an attorney until after mandatory National Practitioner Data Bank reporting requirements had been triggered. Soon after hiring legal counsel, the client’s case went to mediation. A negotiated settlement was reached where the client would resign the specific surgical privileges at issue with the hospital filing an innocuous Data Bank report not citing any violations of the standard of care. Settlement included client retaining all of their other privileges at the hospital.

Client Reviews

What our clients are saying about us

Anonymous

A thorough and experienced lawyer. We are grateful to have Dan and his staff helped us with our case, dealing with Texas Medical Board. Dan is honest, experienced and very thorough. He was supportive throughout the proceedings. His caring and calm nature has made us feel at ease during the whole process. His office staff was professional and responsive. Dan responded to our phone calls and emails promptly. We wholeheartedly recommend Dan and his firm without any reservation.

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Our Practice Areas

Texas Medical Board Defense
Physician peer review and credentialing
Nursing Peer Review
Texas Pharmacy Board Defense
Texas Board of Nursing Defense
Texas Dental Board Defense
Texas Board of Law Examiners Defense
Medicare and Medicaid Exclusions, Payor Audits, and Related Enforcement Actions
DEA Defense
Professional License Defense
BHEC Defense