Enhance The Value You Bring to Your Clients by Helping Them Choose the Right TPA Partner
by David Roosa, Senior Vice President of Sales
One of the most important services you can provide to your self-insured health plan clients is helping them choose the right Third Party Administrator (TPA). Understanding your client’s specific requirements and objectives is critical to creating a win-win relationship between your client and the TPA. For some health plans, basic claims adjudication is all they need. For others, a full-service TPA that offers a comprehensive menu of products and services is the ideal solution. Regardless, the right client/TPA match can be the difference between smooth sailing or stormy waters for your client’s operations and their covered members’ experience.
If you and your client determine a solid claims administration service is all that is needed, here are a few considerations to help you identify the right TPA:
• Is the claims administration staff experienced, knowledge of your objectives and offers a consultative approach helping you manage your plan expenses?
• Are reports clear and concise and do they provide the information you need to make sound strategic decisions? Does the TPA offer custom reporting and analytics on the plan’s data? Is it the TPA’s policy to offer transparency of claims data to the client? Do they have a team of experienced people that helps interpret the data and provide recommendations on how you can meet your plan objectives?
• Can they offer additional solutions that help save you money and are tailored to your objectives like solutions for FWA (fraud, waste and abuse), bill review, OON, stop loss and direct provider contracts.
• Efficient and accurate claims payments benefit your client’s bottom line and enhances its members’ experience.
But what about those clients that need more than simple claims administration? While sound claims administration is the foundation of most TPAs, many health plans have broader needs that the right TPA can help meet. This is especially true in today’s healthcare environment that demands higher quality service, outstanding outcomes, and reduced costs.
We’ve found that brokers can be most effective when they guide their clients through a careful analysis of the plan’s claims history and the health status of the plan’s covered members. This strategic approach will bring the plan’s TPA needs into sharp focus. A plan’s membership that skews older and includes numerous diagnoses of diabetes, heart disease, cancer or other chronic and acute health issues requires expertise in specialty care management, pharmacy benefits management, high-quality provider networks, a strategic approach to stop-loss coverage and a dedication to best-in-class customer service. If the TPA does not provide those services itself, it must coordinate with one or more additional vendors to provide them, or the plan may face higher claim costs.
In your role as an advocate for your health plan clients, helping them structure the right plan design that meets their needs, and the needs of their members, is critically important. If your clients have employees in different geographic locations, does the TPA offer a national network of quality providers (physicians and healthcare facilities)? Maybe your client only has operations in one location so a narrower network is a better option. Does reference-based pricing make sense for this client’s situation? Will your client require wrap-around services such as care management, pharmacy benefits management, and a concierge service to adequately serve the needs of its plan members? Does the TPA offer help with placing stop-loss coverage? A carefully crafted request for proposal (RFP) can capture the precise information needed by you and your client to help facilitate the choice of the right TPA.
Beyond the claims administration and other solutions that work to provide members with access to quality healthcare, there are other variables to consider when managing a self-insured plan. For example, is the client aware of all the new Federal transparency regulations they’re required to comply with? Several new regulations have come into effect with the intended effect of creating greater price transparency for members, to enable them to be better consumers of healthcare services. Responsibility for compliance lies with the plan, but it’s our view that plan sponsors should be able to rely on their TPA partners to provide the resources needed to remain in compliance. Some of those resources are technically complex and may be beyond the scope of service for many TPAs.
Based on decades of working with leading brokers and self-insured plan sponsors, HealthSmart is respected as one of the industry’s leading TPAs. Our reputation is built on our unwavering commitment to providing our clients with innovative solutions and white glove customer service. Here are some of the value-added services our clients have told us they find the most beneficial to their current and long-term success:
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Stellar customer service – More than 90 percent of our clients report being satisfied or highly satisfied with our TPA services. And we achieved a
Net Promoter Score, the measure of customer experience loyalty and satisfaction based on the customer’s likelihood to recommend HealthSmart to others, of 71, ranking us in the “excellent” category and the top one percent for health plans.
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A laser focus on cost savings – In aggregate, over the past three years, our clients have seen their combined medical and pharmacy costs rise a cumulative 6.7 percent, compared to the national average of 19.7 percent.
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Knowledgeable, friendly, responsive advisors – Historically, our
outstanding customer service has been one of the top reasons brokers and their clients continue to choose HealthSmart as their TPA.
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Managing compliance with transparency regulations -- As regulations on health plans, such as the Transparency in Coverage Rule, No Surprises Act and the Consolidated Appropriations Act of 2020 (the so-called “No Gag” rule), continue to develop and evolve, HealthSmart is committed to working with our broker partners and their clients to maintain compliance with all applicable laws. To help clients and brokers better understand these regulations and how HealthSmart supports compliance, we have developed resources that outline key details, and published them to the
Transparency Center on our website. Bottom line: we're taking care of the details, so our clients and their broker partners don’t have to worry about them.
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Personal Concierge member support – High-touch support from a knowledgeable Concierge team that supports members when reference-based pricing is incorporated into the plan design. Clients using our
SmartDecision RBP solution benefit from our negotiations with health systems before the member receives care to ensure provider acceptance and to prevent surprise bills.
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Scalable solutions for health plans of all sizes – From less than 200 members to thousands of members, our service is tailored to meet specific needs.
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Comprehensive Care Management services provide the full range of services to sustain wellness and to coordinate the care of members with serious, rare or chronic conditions that can ruin a plan budget. Our clients see a 9 to 1 Return on Investment from our
Care Management and
Specialty Case Management programs.
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High-quality, cost-effective provider networks – We save health plans dollars through
our proprietary PPO networks, nationwide network partnerships, and effective non-network negotiations.
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Pharmacy benefits management services – Our
HealthSmartRx Solutions team delivers comprehensive high-cost prescription drug solutions, including formulary customization, site of care management, and drug discounts leveraging the power of one of the leading PBM programs in the country. Members have preferred access to 67,000 retail pharmacies nationwide, as well as innovative programs that leverage financial assistance to reduce specialty drug costs by 10-15 percent or more.
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Deep experience with stop-loss placement – We manage more than $1 billion in
stop-loss premiums, working with top-rated carriers and Managing General Underwriters (MGUs) who provide access to the best stop-loss policies available to self-funded plans. Our Reinsurance Team is dedicated to delivering a seamless reinsurance claims process.
As you can see, there’s a lot more that goes into selecting the right TPA for your clients beyond claims administration. As one of the largest TPAs in the country, we know a win-win relationship is built on trust and delivered results. We’ve found that our clients appreciate the variety of products and services we offer beyond plan benefit administration, including care management, pharmacy benefits management, provider networks, and casualty claims solutions. We also offer business intelligence, onsite employer clinics, a variety of health and wellness initiatives, and web-based reporting. Over the years, brokers and their clients have turned to us to be their one-stop source for solutions to meet their needs while receiving best-in-class service, support and insight.
If you’re helping your clients evaluate and select a TPA, take a look at HealthSmart. We have the experience and expertise to help you and your clients maximize the benefits of self-funding. To learn more about why HealthSmart is the TPA partner for you and your clients, email us at
sales@healthsmart.com.
About the Author
David Roosa is Senior Vice President of Sales for HealthSmart. With more than 20 years of sales experience, David oversees HealthSmart’s sales team, providing specialized solutions to manage benefit costs, healthcare reform strategic planning, benefits administration and onsite medical centers to HealthSmart clients.
Prior to joining HealthSmart, David worked with Gallagher Benefit Services (GBS) as the Area Vice President as well as with Cigna, where he held the position of Vice President of Sales. During his time at Cigna, he was responsible for managing an 88 million dollar healthcare plan, covering four states and 25,000 customers. David also spent nine years as a Senior Sales Representative for Great West Healthcare, specializing in self-funded plans.
David graduated from Florida State University with a double major in Marketing and Management.