Customized and objective decisions for the healthcare payer and provider denial resolution process

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.

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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

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STEP 1

Payer and provider contract with TPRI and provide their agreed-upon standards for claim status determinations.

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STEP 2

If a dispute occurs, and the payer and provider cannot successfully resolve it, the case is referred to TPRI for final resolution.

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STEP 3

TPRI reviews the medical record and based on the merits of the case and the agreed-upon standards makes a determination.

Contact Us

Please complete the form below to contact us or to receive more information about TPRI.