1 / 13

ASSESSING THIRD PARTY ADMINSTRATORS: FROM RFP TO STEWARDSHIP

ASSESSING THIRD PARTY ADMINSTRATORS: FROM RFP TO STEWARDSHIP. CLM 207 Monday, April 16, 2012 3:15 p.m. to 4:30 p.m. ASSESSING TPA’S Your Speakers. Barry Wilson – Director, Risk Management – Express – Central Ohio Chapter

karen-lucas
Download Presentation

ASSESSING THIRD PARTY ADMINSTRATORS: FROM RFP TO STEWARDSHIP

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. ASSESSING THIRD PARTY ADMINSTRATORS: FROM RFP TO STEWARDSHIP CLM 207 Monday, April 16, 2012 3:15 p.m. to 4:30 p.m.

  2. ASSESSING TPA’S Your Speakers • Barry Wilson – Director, Risk Management – Express – Central Ohio Chapter • Nathan Hughes – Risk and Claim Manager – Safelite Group – Central Ohio Chapter • Jeff Branca – VP and Client Executive – Hylant Group - Cincinnati

  3. TODAY’S AGENDA • Introductions • Reasons to consider a TPA review • Current TPA environment • Preparation for the process • Managing the reviews • Decision criteria • Stewardship review • Questions & dialogue • Session evaluation

  4. Consideration for a TPA Review • Required due diligence • Service enhancements, industry specialists • Improve costs and/or services • Personnel turnover • Inconsistent service model • Locale considerations • Split claim administration from managed care • Claim(s) gone wrong

  5. TPA Review Preparation • Needs assessment versus current scenario • Initial meetings with TPA’s • Formalizing requirements and standards • Ascertaining decision makers – buyers & users • Weighing the primary criteria & scorecard • Two stage process – • Initial RFP response • Determining finalists • And the winner is… • Communicating the outcome

  6. Needs Assessment – Who & What • Coverage specific • Industry specialists • Claim & category protocols • Medical management • Claim account executive • Designated contacts • File reviews – onsite vs. virtual • Regulatory compliance • Specific adjuster qualifications • Banking requirements • Two year vs. life of claim • Medicare set-aside support • Record retention • Resolving disputes • Insurance requirements • Transition plan

  7. THE INSURERS VIEWPOINT • Insurer retains fiduciary responsibility • Credit risk • Bad faith • Regulatory compliance • Two party contracts • Required interfacing criteria • Massive data • Multiple sources • TPA liability & fidelity requirements • File audits & quality controls

  8. TRANSISTION PLAN • Formalize timelines • Delineate responsibilities • Handling prior claims • Hold initial weekly teleconferences • Supervision by TPA supervisor • Provide frequent & open feedback • Solicit insurer’s perspective

  9. SCORECARD CONSIDERATIONS • General • Experience & capabilities • Specific line of coverage mix • Quality controls -Best Practices • Regulatory compliance • Staffing • Team selection criteria • Workloads & monitoring • Expertise • Economics • Fees & costs • Life of claim vs. contract • Transparency issues • Specific Protocols • Initial reporting & set up • Reserving criteria • Settlement authority • Service agreement • Special instructions • Investigations & surveillance • Claim review criteria • Banking & funding • Insurance requirements • Dispute resolution • RMIS • Capabilities & compatibilities • Benchmarking tools

  10. DECISION TREE • Scorecard review • Required deliverables • Firm’s reputation • Specific account team relationship • References • Transition plan • Ombudsman's access • Ease of termination

  11. STEWARDSHIP REVIEW • What’s the ideal time? • Whose involved? • Critical components - • Summarize of activities • Identify trends & opportunities • Comment on communications • Team & individual performance • Discuss instructions & settlement authority • Intangibles

  12. ASESSING TPA PERFORMANCE Questions And dialogue

  13. CLM 207 ASSESSING TPA PERFORMANCE Thank you for participating Please submit your session evaluation

More Related