Choosing a Benefits TPA

by Clelland Green - Date: 2007-01-21 - Word Count: 736 Share This!

The use of third-party administrators (TPAs) is one of the hottest trends in insurance today. According to the Society of Professional Benefits Administrators (SPBA) 66 percent of all U.S. workers are covered under self-funded plans, most of which are managed by independent, third party administrators. But what do you look for in a TPA? If you're an independent agent, here are some things to consider.

Where to start

Your best sources for TPAs are the SPBA and the Self-Insurance Institute of America. Most high-quality TPAs belong to one of those organizations, which can act as initial filters. Also, don't forget word of mouth. Contact other brokers for their opinion about the TPAs they've dealt with.

Your first step is to determine the needs of your clients. Who are your target customers? And what types of workers do they have? Determine if your customers are fully insured, minimum premium or self-funded. Then, find out what size of self-funded groups they have: small (50-200 employees), mid-sized (200 to 2,000) or large (more than 2,000). This is important because TPAs that serve only large corporations may not be inclined to give proper attention to a company group of 75 employees. Employees kept waiting for insurance cards for two months after enrolling, for example, will complain to their chief financial officer or human resources administrator. They, in turn, will be upset with you.

Next, look for a commonality among the types of customers prospective TPAs serve. Are most of their clients in the manufacturing industry? Or do they serve companies in the technology or government sectors?

Determine whether your target customers are in a single state or if they are spread out. Also, find out what capabilities are important to them. Do they need a provider with online capabilities? Do they need a TPA that can provide self-service for employees? Are they looking for one that provides real-time information on claims?

Once you have a clear understanding of your target customers and the types of employees they have, you can start looking for a TPA that will meet your needs. But not all TPAs are created equal. In fact, if your target customers have multiple needs, you may need to work with more than one TPA.

Questions to ask

Now that you have a list of prospective PTAs it's time to ask some questions at your initial meeting.

- How many employees is the TPA currently serving?

- What types of clients does it serve?

- Does is have a profile customer? If so, does the profile match yours?

- Is the TPA's style a good fit with your roster of clients?

- Which provider networks does the TPA work with?

- What prescription benefit manager does it work with?

- What markets does it have for employer stop-loss insurance?

- Ask for specific information on areas such as claim turnaround time, claims accuracy, inventory control and call-to-answer rate.

- How do they audit and verify the quality of their claims?

- Ask for references.

Find out if the TPA has the ability to accept electronic claims, which streamlines the claims process. Also determine if the TPA manages paper, or if it has its claims scanned and then uses electronic data interchange (EDI). In addition, ask about the TPA's auto-adjudication capabilities. Scanning, EDI and automation will indicate capabilities that will lead to better service.

Does the TPA's claim system have claims-editing capability, and if so, what types of edits are included? A good system will have duplicate claim checking, upcoding and unbundling. For example, the claim system should be able to tell if the claim was unbundled and whether the sex of the claimant matched the service performed.

Next, investigate the TPA's Internet capabilities. At a minimum, these should include enrollment and claims status. If some of your customers are not tech-savvy, find out if the TPA offers interactive voice response capabilities for enrollment and claims status.

Your next step is to ask about the types of reports your TPA can provide. You'll often find that certain reporting capabilities are provided in the base service, while others are available at an extra cost. You'll want to find a TPA that provides reporting capabilities as a base service. Ask if there is an added cost for additional reports.

Lastly, find out if the TPA has call tracking. You'll want requests for service to be automatically delivered through the hall-tracking system. Find out what its service unit can complete without the assistance of other departments. This will cut down on lost time for your clients.

Related Tags: tpa, third party administrator

Clelland Green created Benepath, Inc. in 2004 as a consulting firm to insurers and managed care organizations on Consumer Directed Health Products, including Health Savings Accounts and High Deductible Health Plans. Benepath recently expanded to provide these products and other health insurance plans to businesses and individuals online at

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