URAC Network Management-- v. 5.1 Proposed Revision -- Provider Dispute Resolution

The proposed revisions to URAC's clinical standards are extensive and the deadline for comment draws near. At the very least, however, I'm going to submit one comment. The proposed revisions do nothing substantive to the provider dispute resolution problem that has been getting worse with each revision. I'm surprised -- I would have thought this would be a good time to fix a fundamentally broken series of standards, P-NM and N-NM 13-17. I have written about this at some length (click here to read my blog on the subject of the mess), and URAC has tried to put a bandage on the problem with explanatory notes posted on its website and in AccreditNet. Hardly an elegant solution, when a simple revision of the standards is all that is needed.

So, here's what I'll be sending 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.