Medefense

Medefense provides legal expense reimbursement to a physician who is subject to a disciplinary proceeding. Disciplinary proceedings could mean a review action by the Texas Medical Board (TMB), a hospital action regarding clinical privileges, actions by the Texas Department of State Health Services or the Federal Department of Health and Human Services, and non-compliance with Medicare/Medicaid regulations. In addition, reimbursement for individual federal tax audits is included.

Request Medefense benefits

1. Notify TMLT as soon as you receive the initial letter from the Texas Medical Board (TMB) or other disciplinary authority. The policy states that a policyholder has 60 days to report an insured event to receive reimbursement for covered expenses. To preserve coverage, it is extremely important to pay attention to the 60-day window in which to report knowledge of a proceeding.

   Please call the claim department at 800-580-8658 to report receipt of the following:

   • a review action by a professional review body of a hospital, HMO, PPO, or managed care organization regarding clinical privileges or membership;
   • proceedings instituted by a state medical licensing authority (such at the Texas Medical Board) for unprofessional conduct;
   • proceedings instituted by a professional review organization related to compliance issues under Medicare rules;
   • proceedings instituted by a state department of insurance, state worker's compensation commission, state department of health or federal department of health and human services alleging performance of medical services in excess of or in violation of guidelines;
   • proceedings by a state or federal agency involving allegations of noncompliance with Medicare/Medicaid regulations or guidelines, to include Recovery Audit Contractor program;
   • proceedings alleging violations of EMTALA, HIPAA, or Stark laws; or
   • formal written notice that your individual federal tax return is under examination by the Internal Revenue Service.
2. Consider retaining an attorney to help draft your initial response to the disciplinary authority. Upon request, TMLT can provide policyholders with the contact information of attorneys who have experience handling disciplinary proceedings. Retaining an experienced attorney as early as possible in this process can help to shape the case. It can also facilitate a clear, concise, and objective response to the complaint.

3. To expedite the reimbursement process under Medefense, promptly send the following information to TMLT:

   • a copy of the initial written notice/letter informing the policyholder that a disciplinary proceeding has been instituted;
   • copies of all legal expense invoices pertaining to the defense of the claim — the legal or audit expenses should be itemized on an hourly basis showing the services provided, the time incurred, and the hourly rate;
   • copies of all payments made to the attorney or law firm representing the policyholder in the matter; and
   • a copy of the dispositive letter describing the final outcome so the claim can be closed.

Benefits under Medefense

Medefense will reimburse the policyholder for reasonable legal and audit expenses up to $25,000 per policy period. Medefense claims are subject to a $1,000 deductible and a 10% coinsurance provision (the physician will pay 10% of the reimbursable expenses after application of the deductible). The 10% co-payment clause will be waived if you select an attorney from a panel provided by TMLT.

The coverage for tax audits is limited to a maximum of $5,000 per policyholder, included in the $25,000 maximum reimbursable limit. Please note: the deductible and co-payment apply only to Medefense and do not apply to medical liability coverage.

The TMB can impose a range of disciplinary actions or sanctions, which can include license revocation and suspension, probation, public reprimand, monitoring or other limitation/ restriction on your practice, counseling or treatment, required educational or counseling programs, public service, and an administrative fine. However, Medefense does not reimburse the costs for any CME, counseling, or fines imposed by the TMB (e.g., in an Agreed Order) or the policyholder's travel expenses to attend an Informal Settlement Conference or State Office of Administrative Hearing in Austin.

Read more about Medefense coverage.