Arbitration Workflow

Legislation like the state level No Surprises Act is changing the landscape of non-par reimbursement creating a need for scalable solutions

• Strict guidelines
• Legislated processes require documented follow-up within fixed timelines to retain the right to collect on unacceptably low payments
• High volume
• Impacted claims can be high volume
• Inconsistent payer expectations
• Disparate follow-up protocols are required depending on payer plan
• Large scale solutions
• The complex problem requires a dynamic and scalable solution

The challenge is to create a sub-workflow that manages all the dates for the arbitration process and engage the user at critical points to avoid a loss of opportunity.  The attached Powerpoint contains a high level overview of the federal process to give an idea of the workflow.  If dates are missed the right to pursue action is lost.  Keeping track of this process involves tracking a large number of both derived and user entered values.  A list is provided of those values to highlight the complexity as compared to only creating a follow up record for a contract variance.  Once these values are stored within the system the next step to have a workflow would be using the variables to dictate when records require user engagement to prevent a loss of opportunity followed by new reporting to support oversight. 

It may be helpful to note that this process happens in record batches and not on a one by one basis to maximize the cost to benefit ratio of the IDR fees per batch .