URAC Health Plan and Health Network Provider Dispute Standards (NM 14, NM 15, NM 16, NM 17, and NM 18)

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.