Article | March 22, 2022

ARBITRATION SERVICES – Health Services Claim and Payment Disputes

The Current Environment

Disagreements occur between payer and providers. Beyond the specifics written in the agreements lie the entire nomenclature and industry standards unique to health care and the adjudication of claims. Issues of coverage and specific line items billed are interpreted using the same words but often different expectations. Very seldom is the issue one of advantage but each party wants resolution since they expect to continue in the same marketplace handling the same population.

For many payers and providers, there is a binding arbitration clause so that when there is an unresolved dispute regarding the appropriateness of payment, someone knowledgeable about the industry standards for documentation, coding, billing and adjudication is needed.

Arbitrators are often retired judges who obtain the facts of the dispute and render an opinion. The participants in the arbitration are then required to educate the arbitrator in the peculiarities of medical payments and all its related issues. This can be painful, expensive and not resolve the ongoing issues.

Charlotte Kohler brings the experience of both someone who has worked in the field of health care in all aspects of those issues relating to health care payment, as well as being both the expert witness for arbitration and being the arbitrator – for both the providers and the payers. The timing and costs of the arbitration are based on your contract. But understanding nuances of the health industry payment systems, understanding the facilities and the providers, and the suppliers, and then being able to focus on the specific issues, tends to be more direct and far less costly.