Managed Care Dispute Resolution Protocol: An Overview

With a grant from the Robert Wood Johnson Foundation and in collaboration with New York University, several years ago TMG developed the Dispute Resolution in Managed Care: a Modular Self Assessment Protocol, a tool for assessing conflict resolution systems in Health Plans. TMG later implemented and evaluated the Protocol at six Plans nationwide. TMG was invited to assist three of those Plans in follow up projects. In addition, TMG made numerous presentations about the Protocol at both local and national conferences and audio conferences.

Managed Care Dispute Resolution Protocol: An Overview

The Protocol is an interactive tool designed to allow a Managed Care Organization (MCO) to identify and diagnose problem areas in its dispute resolution system, and, if it so chooses, to go deeper to explore and address the underlying causes of particular problems.
It is structured around what we identified as four key sets of objectives of any plan’s dispute resolution system:

  • Efficiency and Effectiveness
  • Fairness and Integrity
  • Member Satisfaction and Retention
  • Organizational Learning and Feedback

The Protocol consists of the following five inter-related and cross-referenced modules:

Module One: Diagnostic Scenarios. Based upon examples taken from actual disputes, these Scenarios challenge MCO staff members to work collaboratively and cross-departmentally to analyze their current policies and practices.

Module Two: Diagnostic Questions. These Questions prompt MCOs to look from different and new angles at current policies and practices and to analyze their collective assumptions about how well their systems are working.

Module Three: Exploratory Tests. The Tests allow plans to dig deeper into problem areas and explore how well the MCO is performing on various measures; these tests will also challenge staff members’ beliefs and perceptions about the MCO.

Module Four: Promising Practices. Derived in part from an American Bar Association/Robert Wood Johnson funded project, this section gives suggestions for improving problem areas.
Module Five: Individualized Assessment. This section encourages MCOs to create their own questions, tests, or scenarios, and/or work plans to respond to identified problems.
To implement the Protocol, the plan first assembles a Working Group consisting of six to ten individuals from different departments of the MCO. The use of such an interdisciplinary team promotes one of the organizing principles of the Protocol: that the various dispute resolution functions of the plan be viewed systemically. Seeing the Grievance, Appeals and External Review processes and the Customer Service department as one system allows a different and more useful perspective to evolve.

Two facilitators from our team help the Working Group complete the first two Modules (Diagnostic Scenarios and Questions).  Having identified problem areas in their dispute resolution system, the Working Group can then decide whether to proceed, with the assistance of the facilitators, with the remaining three modules (Exploratory Tests, Promising Practices and Individualized Assessment).  

We believe that helping the Working Group go through these modules while keeping in mind the four key objectives will aid MCOs in the following ways:

  • Efficiency: The Protocol will help the plan marshal its resources and design processes to produce cost-effective, well-informed, and timely solutions.
  • Democratization: Increased accountability and fairnesswill benefit a broader range of consumers who may have differing access to resources and differing communications skills and abilities.
  • Communication: As MCOs and patients begin to know more about each other sooner and spend less time and energy fighting with each other,MCOs can spend more time, energy, and money on effectively delivering services.
  • Feedback: Healthy, well-monitored Dispute Resolution systems create opportunities for MCOs to learn about themselves and their members in a uniquely useful way.In this era of cost-cutting and external review, this kind of continuous learning is of critical importance.

State and federal governments are mandating requirements for external reviews, hearings and patients’ rights.  Employers and individual consumers are also paying critical attention to health care systems. By implementing the Protocol, MCOs can begin to take important first steps to increase efficiency and fairness in the delivery of health care services.