Provider Termination

The process by which a provider's participation in a payer's network is ended, either voluntarily by the provider or involuntarily by the payer.

Provider termination is when your network participation with a payer ends. This can be voluntary, meaning you chose to leave the network, or involuntary, meaning the payer removed you. Either way, there are consequences and processes to follow. Voluntary termination usually requires written notice to the payer, typically 90 days in advance. Your participation agreement specifies the notice period and process. Common reasons providers voluntarily terminate include: the fee schedule is too low to be profitable, excessive administrative burden from the payer, contract terms that are unfavorable, or the provider is retiring, relocating, or closing their practice. Involuntary termination happens when the payer removes you from their network. Reasons include: failure to complete re-credentialing, loss of medical license, loss of malpractice insurance, conviction of a felony, exclusion from federal healthcare programs, sustained quality concerns, billing fraud, or violation of participation agreement terms. Most payers have a due process procedure for involuntary termination. You have the right to be notified of the reason, to present your case, and to appeal the decision. NCQA standards require that providers receive written notice and have an opportunity to review and respond before a termination decision is finalized, unless the reason involves an imminent threat to patient safety. Termination has cascading effects. Your patients need to be notified and transitioned to other providers. Pending claims need to be submitted before the termination date. The payer removes you from their directory. And the termination itself may be reportable. If the termination is for cause related to quality or conduct, the payer may report it to the NPDB, which then shows up on future credentialing applications. If you are voluntarily leaving a network, plan the transition carefully. Notify your affected patients well in advance. Submit all outstanding claims before your last day. Request written confirmation of your termination date from the payer. And document everything in case there are disputes later about services provided during the transition period.