Rapid Dispute Resolution Process

Priority Health supports the Michigan Department of Community Health (MDCH) Rapid Dispute Resolution Process (RDRP) for hospitals under the MDCH Access Agreement. The purpose of this policy is to ensure that provider disputes are processed in a timely and efficient manner with adherence to State/Federal regulations. Provider disputes will be reviewed to determine the appropriate resolution.

This policy applies to non-participating hospitals that have a hospital access agreement.

The Rapid Dispute Resolution Process below is used when a hospital has completed the standard Priority Health review & appeal process.

From the michigan.gov website:

Hospital Access Agreement: Rapid Dispute Resolution Process

1. Hospitals and Health Plans agree to exhaust their efforts to achieve reconciliation solutions for outstanding accounts via internal means on a regular ongoing basis, including the use of an Accounts Receivable Reconciliation Group (ARRG), before pursuing the Rapid Dispute Resolution Process (RDRP).

2. Where a disputed claim, or group of similar claims, remains, either the Hospital or the Health Plan may submit a request to the Department for RDRP. Upon receipt of a request by either the Hospital or the Health Plan, the Department will advise the other party that the disputed claim or group of similar claims will be resolved in this manner.

3. The Department will contact a mediator, selecting one at random from the list of available mediators that it has prepared, within fifteen (15) calendar days of election/agreement by both parties to proceed. The mediator will schedule the mediation session within fifteen (15) calendar days of contact by the Department. The mediator will issue his/her decision within fifteen (15) calendar days of the mediation session. The mediators will be disinterested parties without conflict of interest with either the Health Plan or the Hospital.

4. Hospitals and Health Plans agree that, should a Hospital or a Health Plan elect this process, the outcome, including any monetary award, will be binding. Both parties agree to assume the burden of cost for presentation of their positions before the mediator. The cost of the mediator will be borne proportionally.

5. If the Hospital's position is granted, the Health Plan agrees to make payment for the disputed claim(s) within thirty (30) days. If the Health Plan fails to make payment within the required timeframe, the Department will enforce the decision through a withhold of the disputed amount from the Health Plan’s capitation payment and direct payment to the Hospital.

6. If the Health Plan's position is granted and results in the Hospital obligated to reimburse the Health Plan, the Hospital agrees to make payment within thirty (30) days. If the Hospital fails to make payment within the required timeframe, the Department will enforce the decision through an adjustment of future Hospital payments and direct the disputed amount to the Health Plan.