ASSESSING THIRD PARTY ADMINSTRATORS: FROM RFP TO STEWARDSHIP

CLM 207Monday, April 16, 20123:15 p.m. to 4:30 p.m.

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

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

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

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

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

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

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

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

DECISION TREE

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

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

ASESSING TPA PERFORMANCE

Questions And dialogue

CLM 207 ASSESSING TPA PERFORMANCE

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