Once these claims are identified, you and the insurer can set up procedures to resolve them. For instance, under the terms of the agreement, you and the insurer can agree to submit the unresolved claims to binding medical review. Instead, the agreement should provide that the reviewer, mutually selected by the parties, be an independent doctor with board certification in your field. The agreement should state that the reviewer's decision is binding and nonappealable, except when the reviewer has an undisclosed conflict of interest or material bias. Ongoing procedures and practices To ensure that they avoid similar disputes in the future, the parties should use the agreement as an instrument to establish ongoing billing procedures and practices that will move future claims toward resolution in an orderly and timely manner.
Claim evaluation is at the heart of the matter, of course.
To make this promise meaningful, the agreement should impose a penalty on the insurer if it's in violation. For example, you could include a clause saying the insurer must pay interest on all claims not paid or determined in good faith within 30 days of submission. Also, to the extent possible, require the insurer to designate one of its employees as the principal contact person charged with responding to your claims and appeals. By establishing a direct line of communication, the parties should be better able to head off future disputes or, at the very least, to efficiently process such disputes. Draft to avoid recurring problems.