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.