TPA Services

  • Generate detailed monthly premium invoice
  • Reconcile invoice with group enrollment changes
  • Generate reconciled invoice for carrier
  • Review all individual applications and/or change forms for accuracy and submit to carrier for processing
  • Coordinate and assist in enrollment/educational meetings
  • Provide open enrollment notifications and open enrollment assistance as needed
  • Create brochures/flyers for informational and educational purposes
  • C.O.B.R.A. administration
  • General member services which include claims resolution, pre-certification and pre-determination of benefits, provider issues, coordination of care and other issue resolution
  • Third Party Administration Oversight For Fully Insured and Self Insured Group
  • Reduced Claims Expenses
  • Reduced Administrative Expenses
  • Improved Membership Satisfaction
  • Improved Accuracy of Billing
  • Higher Recovery of Erroneous Payments

Services include:

  • Analysis
  • Documentation of Findings in the form of Written Reports
  • Recommendations for Improvement

Available:

  • Implementation (or assistance with) of Recommendations
  • Recovery Services
  • Claims Audit

    Comprehensive audit of paid claims with focus on timeliness, accuracy, consistency, documentation and appropriateness. Accuracy focuses on eligibility, authorization, pricing, coding, covered services, calculation of reprice, volume of services, benefit levels, member portions, discount levels, etc.

  • Eligibility Audit

    Comprehensive audit of membership eligibility and demographic data used in benefit eligibility, authorization, insurance premiums, dues, employer billing and documentation.

  • Retroactive Adjustments Audit

    Comprehensive audit of all "retroactive" transactions as related to eligibility, insurance premiums, dues, employer billing and documentation.

  • Provider Network Assessment

    Detailed assessment of the current provider network with specific focus on geographic coverage, quality, accessibility to hospitals, primary care and specialty physicians, pharmacies and other ancillary providers and the level of discounts available and actually realized based upon actual experience.

  • Discount Pricing Assessment

    Thorough analysis of actual pricing discounts realized based upon the existing provider network and detailed by type of service such as inpatient, outpatient, professional, etc.

  • Claims Discount Negotiation

    Negotiation of:

    • Out-of-network claim discounts
    • Individual high-dollar claim discounts
    • High utilization/high volume provider contracts
    • Bulk settlements
    • Preferential relationships
  • Intermediary Services

    Professional intermediary services focused on conflicts, misunderstandings and attempted resolution of matters related to claims denials, discount denials, authorization denials, appeal denials, insurance benefit issues and other similar matters.

  • Reinsurance Recoveries Audit

    Comprehensive audit of available and realized reinsurance recoveries/savings based upon actual claims experience.

  • Medical Management Review

    Detailed assessment of the entire medical management and utilization management processes with a focus on communication, accessibility, timeliness, authorization process, denial process and the related errors, accuracy, complaints, appeals and financial savings.

  • Denials, Appeals & Grievance Assessment

    Focused review of the volume and nature of denials, appeals and grievances related to authorizations and claims.

  • Recovery Services

    Identification, documentation and recovery of claims payment errors, insurance premium payment errors, dues billing errors and other related recoverable matters.

  • Operational Assessments

    Assessment of administrative services, claims processing, dues and billing, accounting/bookkeeping, insurance premiums/coverages/benefits and other related administrative matters focused on processes, policies, procedures and staffing with recommendations to improve efficiency, reduce expenses, minimize errors and improve communication.

  • Interim Management Services

    Interim management for levels of the organization.