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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

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ASSESSING THIRD PARTY ADMINSTRATORS: FROM RFP TO STEWARDSHIP

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  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

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