Case Study: Which TPA to partner with?

Which TPA to partner with?

One of the challenges commonly faced by regional clients is related to difficulty securing a seamless standard customer journey to access healthcare services across all operations or countries. This could be due to several reasons such as processes, benefit design, TAT for reimbursing, among others. Processes differ when agreements are done directly between insurer and providers rather than TPA and providers. 

Due to this variation in processes provider’s staff, insurer’s staff or patients’ may be unclear about means to handle inquiries, claims approval or adjudication. Unfortunately, this leads to delay in approval, claim settlement or responses which cause patients to complain to Human Resources. As the number of complaints increase, the client will escalate to brokers and eventually insurer need to find a solution or client’s whole portfolio renewal will be at stake.

Choosing best TPA to partner with is a cumbersome yet rewarding process. Several TPA components need to be evaluated in presence of many stakeholders from TPA and insurer’s end and finally a consolidated cost benefit report will determine which TPA best suits insurer. To name a few, tariff agreements, comprehensive provider network, system automation, call center metrics, claims adjudication and processing metrics, data and analytics, reporting, client management, reputation, telehealth, etc. Upon comprehensively assessing each component and scoring it the cumulative score will make TPA stand out. Now, how fast TPA uploads member’s data, benefits and issuance of insurance cards (whether hard copy or electronic one) will facilitate ease of attaining healthcare services (inpatient, outpatient or pharmacy). This is actually what patient’s really care about having the ability to reach providers easily and getting healthcare services which are medically necessary as per benefit design they paid for.