The current dispute resolution process between healthcare payers and providers is cumbersome and inefficient. Because payers and providers do not usually establish a mutually agreeable set of standards to determine claim status, there are no clear guidelines for deciding whether a claim should be considered inpatient or outpatient. Thus, an acrimonious relationship ensues between parties that share common interests.
TPRI was founded to be a neutral alternative using a denial resolution process that is customized, objective and fair.
A fair denial resolution process
The Problem
When a payer and provider disagree on claim status, the traditional method of resolving this conflict follows a cumbersome and resource intensive process that frequently results in a strained relationship, leaves cases unpaid, and increases payer-provider tensions.
The TPRI Solution
TPRI offers a better way for claim status resolution between payer and provider by supporting the parties in the development of review standards and by using our 3-Step Process that results in unbiased and independent decisions.
Why TPRI?
TPRI is the only organization in the industry that provides:
- A model that ensures payer and provider agree upon standards to be used for inpatient and outpatient medical claim dispute resolution
- Unbiased, objective and impartial physician reviews based on the documentation by the treating physicians in the hospital EMR
- A mechanism for consistently and impartially applying expert knowledge to medical claims decisions
How We Work
STEP 1
Payer and provider contract with TPRI and provide their agreed-upon standards for claim status determinations.
STEP 2
If a dispute occurs, and the payer and provider cannot successfully resolve it, the case is referred to TPRI for final resolution.
STEP 3
TPRI reviews the medical record and based on the merits of the case and the agreed-upon standards makes a determination.