Pharmacy Challenges Wrongful Enrollment Denial and Wins

Posted on Firm News by Erin Ferber

Successfully enrolling or recredentialing as a provider in an insurance network can be challenging regardless of whether you are seeking enrollment in a federal or state funded program, or with a commercial carrier.  In recent years, many insurance carriers have contracted with third-party’s to oversee the credentialing process although the insurers remain the determiner of which applicants ultimately are allowed into the network.  Unfortunately, however, many of the third-party contractors are inept or unable to adequately evaluate applicants oftentimes resulting in improper enrollment denials or wrongful terminations.

After being denied enrollment in the Humana network, a South Florida pharmacy contacted Nicholson & Eastin, LLP, to determine what options were available to challenge the decision.  The basis for the denial was several alleged deficiencies identified by the third-party contractor and which were referred to Humana, all of which were unsubstantiated.  Since being an in-network provider is a privilege and not a right, applicants are at a disadvantage when it comes to wrongful denials or terminations.  More specifically, insurers can deny applications without allowing the provider an opportunity to appeal or even discuss certain findings made during the application process that were incorrect.  Despite the fact that the South Florida pharmacy had no formal appeal rights, Nicholson & Eastin, LLP, contacted Humana and its third-party contractor to provide information and documentation previously provided during the application process which contradicted the third-party contractors findings.  Humana re-evaluated the application and determined there was no basis to deny the pharmacy’s enrollment and offered it an in-network pharmacy contract, which it accepted.

Nicholson & Eastin, LLP, regularly assists providers with enrollment issues, including wrongful enrollment denials, terminations and/or revocations.  Please do not hesitate to contact us for assistance with either type of matter.