How TPA is improving health insurance claims processes
What is a Third-Party Administrator?
According to the business dictionary, Third-party administrator is an organization that administrates group insurance policies for an employer. This organization works with the employer as well as the insurer to communicate information between the two, as well as processing claims and determining eligibility.
Understanding Third-Party Administrators
The delivery, administration and claims adjudication services has historically been dominated by large insurers with names you’d be familiar with. But there’s another player in town that operates in the same space with a focus on small to medium-sized businesses – the Third-Party Administrator (TPA).
What is the role of third-party administrators (TPA) ?
TPAs are also significant players in the health care and managed care industry and are normally contracted by a health insurer or self-insured business (for health coverages purposes) for:
Claims adjudication and payment
Medical case management
Network access on cashless basis
Full back office support and service
Cost containment tools and negotiation with medical providers
Customer service hotline support
Anti-fraud tools
On site visits
On the self-insurance front and by way of example, a hospital or provider organization desiring to set up its own health plan will often outsource certain responsibilities to a TPA.
TPA or health insurance ?
We can say that each service can be linked to the other one, here is why: Health insurance companies and self-insured companies often outsource their claims processing to third party administrators (TPA). In fact, Third-party administrators (TPA) provide a variety of services to the insurance industry. For some companies, they help expedite claims while providing timely customer service and helping to maximize a customer’s assets. They may also provide risk management, billing services, data and analytics, and in some cases subrogation expertise.
TPAs and Insurers are different in a couple of keys ways
Firstly, TPA generally only take on certain functions and don’t usually have products of their own. This often allows additional flexibility in coverage and more tailored solutions rather than off-the-shelf benefit designs typical from larger Insurers.
Secondly, due to the their scale, TPA are well-known as being able to provide greater, more personal levels of customer service, enrollment assistance, and dealing with inquiries. At Youna-IHS, because your health is our priority, we dliver personal assistant with a local staff that you can contact here.
TPA solutions: supporting medical experts
A hospital or a health provider organization that sets up its own health plan will often outsource the administrative responsibilities to a third party. A company which opts to self-fund its employee health insurance plan typically contracts with a third-party claims administrator to run the program.
Youna-HIS sums it pretty well: “the role of TPA is to connect insurance companies, policyholders and health care providers.”
