The Basics

After a decade of dealing with provider dispute resolution accreditation standards, we have concluded that it is best to deal with them as a whole, rather than individually.  Under these standards, your organization must have a well-developed mechanism for resolving significant disputes with providers.  Typically, those providers disputes come in two categories, administrative and clinical/professional.  While it is possible that you will have a single provider dispute resolution mechanism for all of these disputes, it is more likely that your organization has chosen to provide different dispute resolution mechanisms for these two categories.  The "due process" afforded to providers in a clinical/professional dispute resolution process is more robust and expensive to administer than the required processes for administrative dispute resolution.

In any event, these standards require that your policies and procedures for provider dispute resolution clearly articulate that process in a way that providers can understand, provide for specific time frames for each step in the process, and have clear descriptions of the process by which providers may seek redress and appeal decisions made in the process.  In addition, these policies and procedures must be developed and reviewed with the involvement of participating providers no less frequently than annually.

The minimum requirements for "due process" for these two types of provider disputes are as follows:

• Clinical/professional (e.g., related to professional quality of care or conduct):
  • two levels of appeal
  • each appeals panel is comprised of at least three persons
  • each appellate panel has at least one participating provider who is not otherwise involved in network management and who is a clinical peer of the disputing provider
  • the provider may present relevant information at each level of appeal, although not necessarily in person
• Administrative:
  • the provider has a mechanism for the presentation of relevant information
  • the provider's issue will be considered by an authorized representative of the organization who was not involved in the initial decision that is the subject of dispute

Management Tips

Nearly all first-time applicants will need to modify their existing policies and procedures to accommodate these standards' requirements, particularly the requirement of having a second-level appellate panel composed of at least three people, one of whom is a participating provider who is a clinical peer of the disputing provider.

Most organizations house these dispute resolution policies and procedures within their credentialing program.  Therefore, this language probably should be in their credentialing plan or credentialing policies and procedures.

Another often-missed requirement of this set of standards is that your policies and procedures for provider dispute resolution be annually approved by participating providers.  This most frequently is met by having the standards come up for annual review by the credentialing committee, which has to review all credentialing policies and procedures in any event on an annual basis.

URAC Accreditation Tips

All of these standards carry a weight of 4, and most of the elements are primary.

For all of these standards, you should submit your applicable policies and procedures, as well as any sample correspondence associated with provider dispute resolution.  In addition, it would be helpful to submit minutes from committee meetings demonstrating provider approval of the policies and procedures, as well as any minutes from appellate panels involved in provider dispute resolution.

For the on-site review, you will be asked for a list of complaints, grievances and appeal submitted by providers over the last year.  From that list, the reviewer will select sample provider disputes to a sure that your dispute resolution in those cases was conducted according to policies and procedures and the applicable standards.  In addition, your senior staff members and medical director will be interviewed on how disputes are handled.

In 2008, the initial proposed revisions to URAC's Health Plan/Health Network provider dispute resolution standards did nothing to address the years-old confusion that, as I've reported here, has gotten more acute with each revision.  In an effort to help sort out the issue, I sent URAC a comment during the public comment period for the revision.  

In December 2008, the URAC Board adopted changes to the standards that, I am told are much like what I recommended.  The new standards will be published in April 2009.

Here's what I sent URAC on this topic:

The problem with NM 13-17 is this – the titles of the standards, as well as the clarifying information of URAC, suggests that this is intended to design a two-track system, one process for administrative disputes and another for clinical conduct disputes. A close reading of the standards, however, demonstrate that the standards actually create a single 3-level process. A simple way of describing the standards, as written, is to say it this way:
Any dispute that involves either network status (termination or suspension) or professional conduct/quality must afford the disputing provider 3 levels at which he/she can seek redress:
(a) An authorized person in the organization who was not involved in the first decision;
(b) A first-level appeals panel with at least three people including a clinical peer not involved in the earlier decisions;
(c) A second-level appeals panel with at least three people including a clinical peer not involved in the earlier decisions.

It is clear from URAC's labels for NM 15 ("Type A - Administrative") and NM 17 ("Type B -- Peer Review Panel") that this is not what URAC is trying to do with these standards.

The proposed modification for v. 5.1 makes no effort to modify the language of the standards to achieve URAC’s intent. This disconnect between intent and language is not only bad for URAC and URAC’s accredited companies, it is unnecessary. The following modification would accomplish what URAC says it intends, but would do so in the body of the standards themselves:

Standard 1 – Disputes Concerning Professional Competence or Conduct
The organization implements a mechanism to resolve disputes with participating providers regarding actions by the organization that relate to a participating provider’s status within the provider network and any action by the organization related to a provider’s professional competency or conduct. That mechanism:
(a) Specifies that all disputes are referred to first-level panels consisting of at least three qualified individuals, of which at least one must be a participating provider who is not otherwise involved in network management and who is a clinical peer of the participating provider that filed the dispute;
(b) Includes the right to consideration by a second-level panel and the methods to request such consideration, and a mechanism for providers to present relevant information; and
(c) Provides for consideration to a second-level panel consisting of at least three individuals that comply with Standard 1(a) and that were not involved with the first-level panel.

Standard 2 – Disputes Concerning Administrative Matters
The organization implements a mechanism to resolve disputes with participating providers not covered by Standard 1 that offers the disputing provider the right to consideration by an authorized representative of the organization not involved in the initial decision that is the subject of the dispute.

Standard 3 – General Requirements for Provider Dispute Resolution Mechanisms
The dispute resolution mechanisms described in Standards 1 and 2:
(a) Are available to any participating provider that wishes to initiate the dispute resolution mechanism;
(b) Rely on written policies and procedures that:
i. Are developed and reviewed at least annually with the involvement of participating providers;
ii. Clearly describe the dispute resolution process, including the right to consideration by an authorized representative of the organization not involved in the initial decision that is the subject of the dispute;
iii. Include the methods to request such consideration; and
iv. Include a mechanism for providers to present relevant information; and
(c) Provides for explicit time frames.

In amending this standard, which describes an aspect of the provider dispute resolution process for clinical and quality disputes, URAC simply clarifies that its use is limited to participating providers. It does so by amending subsection (b) to read, “Includes the right to consideration by a second-level panel and the methods to request such consideration, and a mechanism for participating providers to present relevant information.” The new language is simply the word “participating”.

For a more complete discussion of URAC's provider dispute resolution standards, see my earlier blog.

One of the two biggest controversies in URAC Health Plan and Health Network standards interpretation in the last 5 years just got more confusing: provider dispute resolution.

A little history helps. Back in 1998-2000, v. 2.0 listed every conceivable type of provider dispute and said that the URAC two-appeal, par provider on each appellate panel, dispute resolution system applied to all of them. Version 3.0 complicated matters by getting rid of the list of dispute types. When, as URAC’s main reviewer for the NM sections of the Health Plan and Health Network programs, I continued to apply the requirement to all provider disputes, URAC applicants complained that I was applying it too broadly.

At my recommendation, one such complaining applicant appealed to the URAC Accreditation Committee, arguing that the URAC-required dispute resolution system should apply only to clinical matters. The Accreditation Committee agreed with the applicant, and instructed me to draft language for the Interpretive Guide that explicitly limited its application to the kinds of disputes that are the subject of Quality Act reporting requirements. I did so, and my language ended up in the v. 3.2 Interpretive Guide.

The URAC Standards Committee then took my language and, with an apparently minor tweak, turned it into a standard in v. 4.0. However, the “minor” tweak was huge: by substituting its “or” for my “and”, the Committee extended the scope of the requirement back to a breadth reminiscent of v. 2.0 – any dispute that was related either to a termination/suspensions or quality/professional conduct. At first, I thought it was a typo, but an examination of minutes of that meeting revealed that it was a conscious choice by the committee.

Well, applicants started to complain as I (and the URAC Accreditation Committee) applied the v. 4.0 standard. A joint meeting of the Standards and Accreditation Committees in late 2004 did not resolve the issue. The committees and URAC staff asked me to draft language to make two appeals processes, with the current process limited to “quality-related” disputes and a new, less cumbersome process for administrative issues. That language was adopted, with very minor change, by the Standards Committee and sent “upstairs” to the URAC Board for ratification.

Instead of ratifying the Standards Committee solution, the Board sent it back to the Committee to rework. I was not privy to the Board meeting, and cannot say why. I trust there were good reasons for doing so. The Committee, at that point, decided to give up on fixing the v. 4.0 standards and, instead, to take up the issue in v. 5.0 discussions.

In July 2005, I stopped doing my 25-reviews-per-year for URAC as a reviewer and turned my attention to other healthcare consulting adventures. Somewhere in there, the committee took a completely different approach and created the new system, which bears none of my two-track draft language from the ill-fated 4.0 fix.

I won't bother you by copying here the way it reads now.  The truth is that it is filled with inconsistencies and impossible gaps, and reading it verbatim is more likely to cause headaches and confusion than clarity. 

I confess that for some time I did not understand this new approach. It retains the “or” language in the new NM 14, and thereby on its face creates no separate track for administrative disputes. Several folks I’ve talked to report that the word is that, despite the clear failure of the language to create a separate track for such disputes, that the intent of the standard (and the application by URAC reviewers of the standard) is that the full 2-tiered appellate system apply only to quality-related disputes.

Since the initial release of this version of the standards, URAC updated its AccreditNet Program Guide on the subject, and, as a result, here's what we now believe to be true about URAC's interpretation of these standards:

The intent of the v. 5.0 version of these standards, as we suspected, is to establish a two-track system of provider dispute resolution processes. One track, the clinical track (“Type B”), requires two levels of appeal, each of which has a clinical peer of the disputing physician. The other track (“Type A”) is for administrative disputes, such as claims payment, availability for appointments, and the like. Finally, the posting makes it clear that the URAC-required “due process” is not required where licensure revocation or conviction of claims fraud serve as the grounds for the provider’s termination.

This interpretive posting, we believe, should be given more weight than the literal reading of the standards themselves, which we believe will need to be revised again in order to reflect the intent of the drafters.

The real good news is that the next version of the standards, we understand, fix this problem altogether.  But that will be the subject of a different blog post.