Can Anything Be Done About A Dispute In The Medical Setting?

By Brenda Waugh

Consumers and Patients: Have you ever received a medical bill you disagreed with? Had a dispute with a hospital or care facility about the services they provided to you or your loved one? Believed that an error had occurred during your medical treatment? Did you feel like there was nothing you could do?

Health care workers: Have you ever had a dispute with your employer about your hours, wages, benefits, a promotion, or conditions of your employment? Have you had disagreements with your partners or coworkers? Did you try to get along as best you could until you could find another job?

Medical care providers : Have you ever had a conflict with a patient about their care? An unpaid bill? Has your billing office made errors? Have you experienced a conflict with colleagues or a medical facility?

The law provides remedies for most of these situations. For example, in a situation with a billing dispute, the medical provider may be able to report the debt to a credit-reporting agency or may be able to file a lawsuit to collect the debt. Likewise, a consumer may be able to dispute the debt, request verification from the provider, or file a lawsuit.

However, determining your legal right in these situations takes time, effort, and financial resources to resolve the problem. Hiring an attorney, filing a lawsuit, and then engaging in a few years of litigation is rarely the best way to resolve some disputes in health care. Whether the conflict exists between a patient and physician, a nurse and administrator, or a doctor’s group and a medical facility, ADR, or alternative dispute resolution, may provide a better resolution. ADR is gaining popularity in resolving medical related disputes and includes a variety of in- formal processes to resolve disputes and may include mediation, arbitration, or an ombuds program.

ADR of medical-related disputes can occur in a variety of formats. In most any lawsuit, including a medical malpractice case or contract dispute, the matter will be mediated. The parties usually jointly select and hire a mediator to address the issues at some point in the litigation. This may occur before a suit is filed and will nearly always occur before the case proceeds to trial.

In other circumstances, federal and state government-sponsored programs provide for mediators or arbitrators. For example, under the federal law that went into effect last year, the Center for Medicare and Medicaid Services (CMS) will provide a free “neutral” to review bills exceed- ing the estimate for uninsured patients. In addition, the Commonwealth of Virginia provides an alternative dispute resolution process when a provider has a dispute with an insurance carrier about coverage; an arbitrator is appointed by the Virginia SEC to resolve the dispute. Similarly, CMS provides a mediator for disputes between providers and Medicare.

Virginia funds a program providing for a neutral, or an ombudsperson, to help resolve disputes arising in long term care. This neutral can evaluate complaints filed on behalf of older adults and address disputes without litigation. Another program in Virginia operated by the Virginia SCC is the Office of the Managed Care Ombudsman. The Office pro- between the disputants. What can consumers, medical care providers and facilities do to reduce the potential risks and costs of litigation mediation?

For consumers or patients: vides a neutral for Virginia consumers whose health insurance is provided by a Managed Care Health Insurance Plan (MCHIP), such as a Health Maintenance Organization or a Preferred Provider Organization and have a dispute about a coverage decision.

If you disagree with your medical providers about their care recommendations, course of treatment, or a bill, bring it to their attention.

• Inquire as to whether or not they employ an ombudsperson or neutral.

• Find out if they are willing to discuss the issues in a facilitated discussion.

• Talk with an attorney to see if there is a course that will protect your interests and so forth.

Some medical facilities and medical providers engage ADR professionals to resolve conflicts within a facility. The provider may employ an ombudsperson, or they may refer the case to an in-house mediator or contract with an independent mediator. For example, INOVA has a process for disputes between physicians where the dispute is referred to a board that may employ a mediator. Other facilities employ independent mediators who are selected by agreement ronment to provide quality medical services.

When addressing healthcare, it is possible to create the potential for win-win resolutions to disputes, providing the optimal opportunities for wellness. Being mindful of both legal rights and alterative dispute resolution processes increases the chance for everyone engaged with the medical system to be satisfied with the process, and outcomes.

Waugh is a lawyer/ mediator with Waugh Law & Mediation, serving clients in the Blue Ridge region of Virginia and Eastern Panhandle of West Virginia.

For medical facilities and providers:

1. Consider establishing a process for consumers to have a neutral to discuss their complaints. The neutral can be retained with an informal arrangement on a case-by-case basis or may include an ombudsperson on staff. Agreements for services may include provisions requiring or encouraging mediation when a dispute arises.

2. Even without a formal process, provide consumers with information on bringing their complaints informally with an opportunity to be heard.

3. Modify any process to apply to all disputes in the facility, including conflicts with employees and with physicians. Addressing dispute resolution upfront can be forward-focused and create the optimal envi-