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Tip of the week: track and manage disputed claims to prevent recurrence

Managed Care Weekly Advisor, September 26, 2007

Meeting individually with payers can help to reduce the number and types of disputed claims a provider encounters. A recent meeting between representatives from Tenet Healthcare Corporation's managed care, dispute management, and corresponding payer specialists resulted in several disputed claims management strategies that emerged from working with payers:

  1. Find clear contract terms. Identify must-have terms in managed care contracts. Delineating specific terms is crucial in reducing the potential for contract disputes later in the process.

  2. Set achievable contract terms and adhere to them Don't accept contract terms that the payer will be unable to administer, and make sure that activities using words such as "will," "shall," and "must" can actually be performed.

  3. Clarify definitions. Confirm that the definitions of key terms that will be used extensively throughout the contract, such as "covered service" and "medically necessary," are understood by both parties.

  4. Hold up your end of the bargain.Exclude contract terms that may create onerous obligations for the provider, such as the ability to access and copy records. Overextending responsibilities can lead to further conflict.