Healthcare Dispute Resolution

Every day, I come across policyholders venting on social media—not out of anger, but out of sheer helplessness. We buy insurance to protect our families from the unexpected. Yet, disputes between hospitals, TPAs, and insurers are steadily eroding trust. Yesterday I saw a Beshak.org Insurance discussion on premium hikes triggered by new health conditions discovered after purchase. For clarity: new illnesses that arise post-issuance shouldn’t become a reason to cancel a policy or load premiums at renewal unless there was proven non-disclosure or fraud. This is what the ecosystem needs to uphold—consistency and fairness. On the claims side, “reasonable & customary” deductions are often used to trim payouts. The clause is permitted, but insurers must evidence that the hospital’s charges are above what’s customary—otherwise, the cut isn’t fair. Policyholders deserve transparent, line-by-line explanations—not jargon. IRDAI has also tightened service timelines—cashless pre-auth decisions within about an hour and discharge approvals within 3 hours—so patients aren’t left waiting in distress. Let’s make sure these timelines are honoured at the bedside, not just on paper. And remember, with the newer health rules, the moratorium period has been reduced to 5 years—keep your policy active, and after five claim-free years (barring fraud), old non-disclosure disputes shouldn’t haunt you. This change was meant to reduce long-running uncertainty for families. My ask to the ecosystem: Put patients first at the hospital desk—explain what’s payable, what isn’t, and why, in simple language. Stop email ping-pong between hospital, TPA, and insurer. Create a single triage desk with accountable ownership. Publish anonymised claim-deduction benchmarks so everyone knows what “customary” actually means. Proactively educate customers at admission on room-rent caps, sub-limits, and documentation—before a deduction appears. Policyholders don’t need sympathy—they need clarity, fairness, and timely decisions. Let’s rebuild trust, one transparent claim at a time. #knowyourpolicy #insurancesamadhan #policyholder #polifyx #healthclaims #claimrejection #IRDAI

> 90% of strategies claim to be patient-centric. Most don’t involve a single patient. We speak to KOLs and call it patient insight. That is still second or third hand info. Too much gets lost in translation. If patients are the people we serve, their words must shape what we plan and do. Here are five ways that may help have a more patient-centric strategy: 1️⃣ 𝗟𝗶𝘀𝘁𝗲𝗻 𝘄𝗵𝗲𝗿𝗲 𝗽𝗮𝘁𝗶𝗲𝗻𝘁𝘀 𝗮𝗹𝗿𝗲𝗮𝗱𝘆 𝘀𝗽𝗲𝗮𝗸 → Reddit, YouTube, Facebook, disease forums etc. → Notice recurring phrases on pain, fatigue, stigma, costs → Capture three quotes that reveal needs you had not mapped → Run a misalignment check vs your patient journey map e.g: your map says “adherence drops at month 3” Patients say “week 2 side effects make work impossible” 2️⃣ 𝗟𝗲𝗮𝗿𝗻 𝗳𝗿𝗼𝗺 𝘁𝗵𝗲 𝗰𝗶𝗿𝗰𝗹𝗲 𝗮𝗿𝗼𝘂𝗻𝗱 𝘁𝗵𝗲 𝗽𝗮𝘁𝗶𝗲𝗻𝘁 → Pharmacists see access barriers and workarounds → Nurses hear what short consults do not surface → Caregivers share logistics, burnout, hidden costs → Treat caregiver burden as its own need in your plan e.g: mornings are chaotic for carers Once-daily dosing is not nice to have. It is essential 3️⃣ 𝗣𝗮𝗿𝘁𝗻𝗲𝗿 𝘁𝗵𝗿𝗼𝘂𝗴𝗵 𝗽𝗮𝘁𝗶𝗲𝗻𝘁 𝗼𝗿𝗴𝗮𝗻𝗶𝘀𝗮𝘁𝗶𝗼𝗻𝘀 → Join forces on their events within compliance rules e.g: join the walk, offer venues, or materials they requested → Build public disease awareness with trusted groups e.g.: sponsor a short symptom video shared via appropriate channels → Co-create small tools the community asked for e.g.: plain language explainers, clinic checklists, question cards 4️⃣ 𝗕𝗿𝗶𝗻𝗴 𝘁𝗵𝗲 𝘃𝗼𝗶𝗰𝗲 𝗶𝗻𝘀𝗶𝗱𝗲 𝘆𝗼𝘂𝗿 𝘄𝗼𝗿𝗸 → Create a patient word bank of real phrases and use it in slides → Run patient advisory boards to hear directly from the patients → Invite advocates or caregivers to safe internal learning sessions → If permitted and compliant, do a short observership in clinic e.g: invite a patient advocate to your monthly company townhall to raise awareness on the disease 5️⃣ 𝗠𝗮𝗸𝗲 𝗶𝘁 𝘃𝗶𝘀𝗶𝗯𝗹𝗲 𝗶𝗻 𝗲𝘃𝗲𝗿𝘆 𝗽𝗹𝗮𝗻, 𝗻𝗼𝘁 𝗼𝗻𝗲 𝘀𝗹𝗶𝗱𝗲 → Tie each tactic to a documented patient need → Close the loop by showing what changed because of input e.g: include more specific patient reported outcomes in RWE Patient-centricity is not a campaign launched once a year. It is a habit that changes how we work. What else would you add from your therapy area or market? --- Follow Kalyx Medical and Myriam Cherif, PhD for more posts like this.

Your words can escalate a patient. Or they can create safety. Patients who've experienced trauma don't always tell you. But their nervous systems remember everything. And the wrong phrase from a well-meaning clinician can send them right back into fight, flight, or freeze. After 25 years in healthcare, I've seen how much language matters. Not just what we say, but how we say it. When a patient is shutting down or dissociating: ❌ "Hello? Are you listening to me?" ✅ "I'm going to give you a moment. I'm right here when you're ready." When a patient is hypervigilant or scanning the room: ❌ "You're safe here, just relax." ✅ "I notice you're looking around. Would it help if I explained who's coming in and out?" When a patient refuses care or a procedure: ❌ "You're making this harder than it needs to be." ✅ "You get to say no. Can you tell me what's feeling scary about this?" When a patient is escalating or raising their voice: ❌ "You need to calm down, or I'm calling security." (yes, this is said multiple times in a shift if someone is not trauma-informed) ✅ "I hear you. Something isn't okay right now. I want to help, tell me what you need." When a patient flinches at touch: ❌ "I barely touched you." ✅ "I'm going to pause. Can I tell you exactly what I'm doing before I do it?" When a patient seems "overreacting" to a minor procedure: ❌ "This is nothing, we do this all the time." ✅ "Your reaction makes sense. What would help you feel more in control right now?" When a patient is throwing food or objects: ❌ "Stop throwing things, or you're going to lose privileges." ✅ "Something is really wrong right now. I'm not going to punish you. Can you show me what you need?" When a patient is crying and can't speak: ❌ "I need you to tell me what's wrong so I can help." ✅ "You don't have to talk right now. I'm not going anywhere." The first responses dismiss, minimize, and escalate. The second responses validate, creates a partnership, and builds safety. Trauma-informed care isn't just about how we treat staff. It's about how we show up for patients who are already carrying more than we know. One sentence can escalate a crisis. One sentence can prevent one. What phrases have you heard that made things worse? Or better? #TraumaInformedCare #PatientExperience #HealthcareLeadership #PsychologicalSafety

The latest New York Times reporting comes the same day CMS released its newest federal IDR data. The headline numbers are striking: approximately 2.6 million arbitration disputes, nearly $15 billion in provider awards, providers prevailing in roughly 85% of determinations, and more than $1 billion paid to certified IDR entities. What began as a narrow dispute resolution process has become a significant industry in its own right. One quote in the article caught my attention. Some argue that insurers are losing on purpose to justify changes to the law. The newly released CMS data are difficult to reconcile with that narrative. Throughout 2025, health plans substantially reduced default losses and increased their payment offers. Yet provider payment demands continued to rise, while plan win rates improved only modestly. Patients remain protected from surprise bills, which is exactly what the No Surprises Act was intended to do. The challenge now is ensuring the arbitration process works the way Congress intended: as a narrow backstop anchored to market rates, not a pricing mechanism that rewards ever-higher payment demands. https://lnkd.in/g93DrUsu

Was the No Surprises Act’s arbitration process meant to be a revenue strategy for health systems? Maybe not, but I predict that in the next few months, more third party vendors will enter this space and eventually they will be absorbed by RCM vendors owned and/or utilized by large health systems. Nutex Health Inc. recently celebrated in a Press Release, attached to an SEC filing, that it contracted with a third-party vendor that successfully pushed 60-70% of its billable visits into arbitration under the No Surprises Act’s Independent Dispute Resolution (IDR) process. With an 80% success rate, the company is now seeing the substantial positve financial impact of its arbitration strategy. As a reminder, the NSA was designed to protect patients from unexpected, often exorbitant, medical bills when they receive care from out-of-network providers they did not choose. Before the law, patients found themselves stuck with massive OON charges, even when they had done everything right—like going to an INN hospital, only to be billed separately by an OON anesthesiologist or radiologist. Congress passed the law in response to years of patient advocacy and bipartisan concern over these unfair billing practices. It created the IDR process to resolve disputes b/w providers and insurers, attempting to ensure fair payment without sticking patients with the balance. The IDR process was meant to be a backstop for true disputes, not an avenue for mass financial maneuvering. But Nutex's announcement and wider data trends confirm that IDR is being used in a manner that could hurt the very people the law was meant to protect. If arbitration becomes the default path for payment disputes, the consequences could be severe. ▪️ Employers and patients will bear the cost as insurers pass along arbitration-driven rate increases. ▪️ The IDR process, already overwhelmed, could collapse. ▪️ Out-of-network providers could become even more profitable, distorting incentives and further driving up costs. ▪️ Insurers might quietly pay out higher provider bills for ASO clients, knowing the money isn’t coming from their own fully insured products but from self-funded employer plans. The list goes on.... Arbitration was supposed to be used as a last resort in good-faith negotiations, but instead it’s being leveraged as a systematic revenue strategy—and if it proves lucrative, you better believe more Revenue Cycle Management (RCM) companies and third-party vendors will flood the market, selling arbitration as a tool to maximize payments rather than resolve legitimate disputes. Jeffrey HoganPreston AlexanderAnn KempskiPeter HayesShawn GremmingerDoug AldeenLee LewisDave Chase, Health Rosetta-discovering archaeologistKevin LyonsMarilyn BartlettPatient Rights Advocate

The federal IDR system is a case study in what happens when you model a market using data from an incomparable system. Congress projected 22,000 disputes annually. They built that estimate from New York, which used a fixed independent benchmark (FAIR Health) that effectively eliminated emergency billing disputes. There was almost nothing to measure. Texas had a comparable system. Arbitration-based, like the federal model. 49,000 disputes in year one, covering 20% of one state. The federal government had the Texas data. They built from New York. By 2024, actual volume hit 1.46 million. More than 100 times the projection. The infrastructure collapsed. The backlog exploded. Physicians waited an average of 150 days for a 30-day process. A projection error of this magnitude, using available contrary evidence, requires either incompetence or a preference for the outcome it produced. https://lnkd.in/gchi-6ia

Are you familiar with the “SPIKES” method to deliver bad news to a patient? I learned this from some colleagues at Ohio State a while ago. It’s from an oncology journal but the method is great for sports rehab as well. I saw a high school athlete sent to me for a 2nd opinion on the status of her ACL reconstruction. I haven’t done one minute of her rehab, but I ultimately had to be the bearer of bad news. At 6 months post-op, she was WAY behind. The tears started flowing, mom was distraught, but the SPIKES method helps get through these discussions. S – SET it up – “I don’t know much about you yet or your rehab to date, but let’s walk through what I found.” P – PERCEPTION of condition – “Let me start with what do you know about how you’re doing and where you think you should be?” I – INVITATION from patient to give information – “Here’s what I found today. Would you like me to explain it in more detail?” K – KNOWLEDGE with medical facts – “There’s a number of things that are limiting your progress. First of all, we have to get symmetrical extension range of motion compared to your other side. Without it, your quad muscles just won’t be at their maximum potential. Most notably, your quadriceps strength is at a 70% deficit compared to your uninvolved side, and your hamstrings are at 50%. You still have a significant level of swelling and you have significant atrophy in your thigh muscle – in other words, your tire isn’t inflated. Collectively, these are things that we need to address to get you back on the court.” E – EXPLORE emotions and sympathize – “Tell me how you’re feeling/what you’re thinking. Is all of this surprising to you?” S – STRATEGY and SUMMARY – “What questions do you have? I’d like to provide you a road map to get on track – are you OK with that? Is there anything else I can do for you?” I usually close with “Look, I know we met about 20 minutes ago and you were sent to me by your doctor. I’m sorry to be the bearer of bad news but there IS a way forward here. I would be delighted to help you any way I can in the process.” This method has really helped me when I have to assess/evaluate someone that is not familiar with me - particularly if they're comfortable and have confidence in another professional. These discussions can go sideways fast - this has been useful. Give this a try, whether it’s someone with an ACL reconstruction or a non-orthopedic/sports condition. It’s been a great tool to help navigate these challenging discussions.

How DRG Is Reshaping Provider–Payer Relations in Saudi Healthcare The rollout of Diagnosis-Related Groups (AR-DRG) by the Council of Health Insurance is more than a billing update — it’s a structural shift in how providers and insurers deal with each other. From service-based to case-based billing. Instead of paying for every line item, insurers now pay one bundled amount per clinical case, based on diagnosis, procedures, complications, and length of stay. Impact on providers: • Medical coding (ICD-10-AM/ACHI) becomes a revenue-critical function, not just compliance. Poor documentation = under-coding = lost revenue. • Profitability shifts from service volume to operational efficiency and clinical pathway management. • Data analytics capability becomes essential to compare actual cost per case against DRG payment. Impact on payers: • Review shifts from line-item approval to auditing classification accuracy — requiring stronger in-house clinical expertise to catch upcoding. • Bundled payments improve cost predictability at the portfolio level. • Disputes move from individual claim denials to disagreements over DRG classification itself, demanding a more clinical/medical arbitration process — still maturing within NPHIES. Shared challenges: digital readiness (NPHIES/SBS integration), workforce retraining on clinical classification logic, and transition-period pricing gaps if DRG weights aren’t recalibrated against real local cost data. Recommendations: 1)     Providers should invest in Clinical Documentation Improvement (CDI) as the bridge between clinical and revenue teams. 2)     Payers should build hybrid clinical-financial audit teams instead of reverting to line-by-line review. 3)     Both sides should establish joint operating committees to review coding patterns and disputes regularly, before they harden into contractual conflicts. Bottom line:  DRG isn’t a pricing tool — it’s a test of how mature the provider-payer relationship really is. Organizations that build clinical, analytical, and negotiation capability early will turn this into a margin and quality advantage. Those treating it as a paperwork change will see rising revenue leakage and disputes. #الضمان_يضمنك #مجلس_الضمان_الصحي #NPHIES #healthcare #Medical_Coding #Saudi_Billing_System #هيئة_التأمين_السعودي #التأمين #شركات_التأمين #مركز_التأمين_الصحي_الوطني #HealthInsurance #RevenueCycleManagement #SaudiHealthcare #RCM #CHI #MedicalBilling #NPHIES #HealthcareFinance #Vision2030 #ClaimsManagement

#Optimizing Patient Safety through Timely, Effective, and Appropriate Communication Effective communication is crucial for patient safety in healthcare. From my experience handling over 100 legal complaints, I’ve found that many could have been avoided with better communication between doctors, patients, and families. Common issues often stem from delays, unclear explanations, or inappropriate information delivery. #Timeliness: Prompt communication is essential to prevent misunderstandings and missed opportunities. Keeping patients informed about their condition, treatment options, and any changes in their care plan helps reduce anxiety and supports timely interventions. #Effectiveness: Communication must be clear and empathetic. Avoid medical jargon and use the "Ask-Tell-Ask" method: ask patients what they know, provide the necessary information, and confirm understanding by asking them to repeat it. This approach ensures that patients are well-informed. #Appropriateness: Tailor communication to the patient’s emotional and psychological needs. Techniques like BATHE (Background, Affect, Trouble, Handling, Empathy) and AIDET (Acknowledge, Introduce, Duration, Explanation, Thank You) address patient concerns holistically. I will discuss the GICEPT tool in a future article. Here are six strategies for enhanced communication: 1. Set a Shared Agenda: Begin interactions by establishing a shared agenda to prioritize topics, ensuring that critical issues are addressed and that patients feel involved in their care decisions. 2. Practice Empathy and Active Listening: Build trust by actively listening, maintaining eye contact, and showing empathy. Though commonly advised, these skills are often underutilized but are crucial for effective communication. 3. Assess Readiness to Change: Evaluate a patient’s readiness for lifestyle changes by asking, “How important is this change to you?” and “How confident are you in making this change?” Align care plans with their motivation and confidence levels. 4. Set Self-Management Goals: Encourage patients to set realistic, measurable goals, such as “walk 20 minutes, three times a week,” rather than giving vague advice. This approach boosts engagement and compliance, leading to improved health outcomes. 5. Close the Loop: After explaining instructions or treatment plans, ask patients to repeat them to confirm understanding. This technique prevents misunderstandings and ensures alignment with the care plan. 6. Implement Open Disclosure: When adverse events occur, practice open disclosure. Communicate honestly with patients and families about what went wrong, acknowledge the error, and explain the corrective actions taken. This approach fosters trust and supports patient safety. Integrating these strategies can enhance patient safety, reduce complaints, and improve satisfaction. Effective healthcare communication is about building trust and prioritizing patient well-being. #HealthcareCommunication #PatientEngagement

More Rules, More Complaints: Why Health Insurance Is Still Breaking Trust? If regulation alone could fix health insurance, India would already be a global case study. Instead, complaints are surging, doubling in six years, despite more rules, more disclosures, and more compliance checklists. Nearly 80% of complaints reaching the Mumbai Insurance Ombudsman relate to health insurance. That number itself isn’t shocking. What’s uncomfortable is why people complain. It’s rarely outright fraud. It’s deductions, partial rejections, policy exclusions, and non-disclosure clauses that customers swear they were never told about. And most of the time, they’re probably right. This isn’t a “bad customer” problem. It’s a comprehension problem. Health insurance products are sold as safety nets but written like legal puzzles. Agents, often under pressure to close, simplify benefits and skip exclusions. Hospitals overcharge knowing insurers will bargain later. The policyholder sits in the middle, assuming “coverage” means certainty. It doesn’t. Regulators have tried. IRDAI has tightened norms. Ombudsman offices exist to resolve disputes. But when hearings take six months instead of three, and thousands of complaints remain pending, resolution becomes another layer of frustration rather than relief. Life insurance tells a parallel story. Around 60% of disputes stem from mis-selling, policies pitched as investments with “assured returns” that quietly vanish after the free-look period. Different product, same root cause: expectation mismatch. Here’s the uncomfortable truth: regulation treats symptoms, not behaviour. Rules can mandate disclosures, but they can’t force understanding. They can penalise insurers, but they can’t rewind a bad purchase decision made on half-information and hope. The real fix lies upstream, before the policy is sold. Clear comparisons. Plain-language explanations. Data-backed evaluation instead of emotional selling. Until buyers truly understand what they’re buying and what they’re not, complaints will keep rising, no matter how thick the rulebook gets. Trust isn’t restored by more paperwork. It’s restored by clarity. #IRDAI #Insurance #Clarity #Data