What is the legal framework for health care dispute resolution?

In Washington State, the legal framework for health care dispute resolution is based on consumer protection laws. These laws are intended to ensure that medical treatment is provided in a safe and cost-effective manner. At the federal level, the Patient Protection and Affordable Care Act (ACA) contains a number of provisions related to dispute resolution. Most notably, it requires health plans to have an appeals process for any denied or challenged claims. This process allows individuals to challenge disputed claims in court if they are not satisfied with the result of the appeals process. At the state level, the Washington State Department of Health has established a Dispute Resolution Program (DORP) to help resolve disputes between medical providers and health plans. DORP is a voluntary, confidential process for resolving disputes without the need for court intervention. Through DORP, health plans and providers can submit documents, ask questions, and present evidence to dispute resolution officers. Ultimately, the dispute resolution officer makes a binding decision. The Washington State Department of Insurance also has the authority to resolve disputes between patients and health plans. The Office of the Insurance Commissioner (OIC) will investigate complaints and decide whether a health plan must pay a benefit that was denied. Finally, the Washington State Health Care Authority (HCA) oversees Medicaid and other state-funded health care programs. HCA has established a fair hearing process to resolve disputes between recipients of these programs and the state. The HCA is also authorized to restrict or revoke a provider’s participation in the Medicaid program in cases of fraud or other wrongdoing.

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What is the legal framework for health care dispute resolution?

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