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So Your RFP Results in a TPA Change, Now What?

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So Your RFP Results in a TPA Change, Now What?. • Jo Ann Wood Manager, Claims Consulting Solutions Bickmore Arizona State University education and experience with clients changing TPAs enables Jo Ann to provide helpful tips for meeting needs of your stakeholders. • Paula Maguire

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• Jo Ann Wood

Manager, Claims Consulting Solutions


Arizona State University education and experience with clients changing TPAs enables Jo Ann to provide helpful tips for meeting needs of your stakeholders.

  • • Paula Maguire

Senior Vice President - Operations

TRISTAR Insurance Group

Brown University education and experience in operations at TRISTAR, Risk Enterprise Management and GAB Robins equips Paula with practical solutions to share.

  • • Lauren Eib

Risk Manager, Department of Finance and Risk Management

Pima County, Arizona

An MBA in Finance from the Virginia Commonwealth University and long term experience in Risk Management enables Lauren to provide real experience in changing TPAs.

what to expect
What to Expect
  • • Devise a strategy for getting the key attributes optimizing your program's effectiveness adopted by new TPA and your stakeholders.
  • • Adopt a plan for communication, data mapping and a smooth transition.
  • • Study the critical elements of a request for proposal (RFP) that attracts a strong TPA.
first strategy
First Strategy

Follow the Golden Rule

  • Be appreciative of the outgoing TPA
      • Gain Cooperation in Making Transition
      • Service = Future Reference
second strategy
Second Strategy

Build Internal Culture:

  • Clarify program goals
  • Maintain regulatory compliance
  • Carry out plans within authority
  • Develop dispute resolution process
reach entity wide organization
Reach Entity-Wide Organization
  • Top claim producing departments
  • Department heads
  • Claim liaisons
  • Key peripheral partnerships
  • Lines of communication
third strategy build relationships
Third Strategy Build Relationships
  • Delegate responsibilities
  • Set performance targets
      • Performance Consistency
      • Claim resolution targets
      • Expense management targets
  • Consider incentives
operations management
Operations Management
  • Understand Your Current TPA Arrangement
      • Notice of Termination
      • Potential Windup Costs in Current Contract
      • Carrier Notification and Approval for Claim Transfer
      • Can You/Should You Take the Tail Claims
  • Announce the Change
      • Internal to Your Teams
      • Outgoing TPA – Account Manager
      • Vendor Partners
      • State Insurance Departments
operations management1
Operations Management
  • Bring the Transition Teams Together
      • Account Managers or Transition Leaders to Coordinate Key Teams
  • Transition Plan Published and Shared
      • Identify Key Tasks
      • Understand Deliverables by Group
      • Establish and Agree on Due Dates
      • Schedule Follow-up Calls and Updates Through Transition
      • Track Progress and Monitor Delays
      • Delivery Checkpoints – Stay Informed
      • Be Ready for First New Claim at New TPA
      • Stick to Your Plan
operations management2
Operations Management
  • Maintain Cooperation from All Parties
      • Ongoing Claim Handling at Outgoing TPA
      • IT Transition Plan
          • Test Files Received Timely
          • Data Mapping Progressing on Schedule
          • Show-Stoppers Identified and Resolved
      • Preparation of Tail Claims for Transfer
          • Schedule and Fund Advance Indemnity Payments
          • Clear Communication to Advance Payment Recipients – Not a Banking Error in Your Favor
      • Your Claim Handling Instructions Published
operations management3
Operations Management
  • First Day of the Last Time You’ll Change TPAs
      • All Transferred Claims Present and Accounted for at New TPA
      • New Claims Intake, PBM, UR, Early Intervention, Crisis Management – Ready to Go
      • Kick Off Meetings
      • Transition Follow-up Meetings
      • Funding in Place
      • Wind-down Complete at Outgoing TPA
making it work
Making it Work

RFP – Six month Process

What Do You Want the TPA to Do?

  • Think about what is currently working well.
  • What isn’t working – how can that be changed to make your WC program better?
  • What don’t you know?

What will you accept as minimum qualifications?

request for proposal
Request for Proposal

Sections of the RFP

  • Glossary of Terms: What is…
    • A Medial Only Claim
    • A Loss Time or Indemnity Claim
    • Incident, Near Miss, Exposure, Accident, Claim
  • Introduce entity, department & WC program
  • Scope of Project – 1 to 2 Paragraphs
sections of the rfp
Sections of the RFP

4. Outline Responsibilities & Authority

  • Risk Management Staff
  • Injured Workers
  • Department (Supervisors, etc.)
  • Attorneys
  • Occupational Providers
  • TPA
sections of the rfp1
Sections of the RFP
  • Regulatory Requirements
  • Stakeholder Flowchart
scope of work
Scope of Work
  • Functional Requirements - Statements
    • Claims Management
    • Medical Management
    • Information System
    • Cost Containment
    • Prescription Plan
    • Litigation Management
    • Regulatory Reporting
scope of work1
Scope of Work

8. Project Plan - Transition Plan

  • List of Questions
    • Based on Functional Requirements & Transition Plan
    • What can you provide that has not been addressed in the RFP?
  • Schedule to go Live
  • Terms & Conditions:
    • Data Ownership
    • Confidentiality & Non-Disclosure
rfp self assessment section
RFP: Self Assessment Section
  • Self Assessment Form to be Completed
  • Questions to be Answered
  • Pricing Sheet to be Completed
insurance for contract
Insurance for Contract
  • Standard Insurance Coverage
  • Technology E & O Coverage including Network Security
oral presentations
Oral Presentations
  • Most Important part of the Selection process
    • Clarifying questions regarding the RFP
    • Meet staff and management
    • Present your RMIS, Claims Process and other services
    • Philosophy – What makes you unique? Why should we hire you?
  • Contract
  • Timeframes
  • Banking
  • Annual Service Agreement – Review & Update
  • Communicate, Communicate, Communicate
  • 1. Risk Management’s Responsibilities
    • Report injury to TPA within 24 hours of injury
    • Investigations & Loss Prevention
    • Identify Recordable Injuries
    • Modified Duty & Return to Work
    • Communication with WC team
  • TPA Responsibilities
    • Claims Management – 3 point contact
    • Medical Case Management
    • Cost Containment
    • Return to Work/Modified Duty
    • Communication with WC team
discussion points rfp process what s right
Discussion PointsRFP Process: What’s Right
  • Assists purchaser in prioritizing needs
  • It is a formalized procurement process and more flexible than the bidding process
  • RFP can provide detail on the entity and needs
  • Oral Presentations allow both parties to communicate directly
  • Pricing can be revised at the end
  • Written proposal becomes part of the contract documentation
discussion points rfp improvements
Discussion PointsRFP: Improvements
  • Include a Table of Contents
  • RFPs are difficult to read & respond to
  • Mandatory pre-bid conferences
  • Vendors include sales material in responses - increases reading time
  • If not awarded the contract, opportunity to learn the weaknesses in proposal
  • How should we negotiate Final Price?
questions final comments and contact information
Questions, Final Comments and Contact Information
  • • Jo Ann Wood


  • • Paula Maguire


  • •Lauren Eib