4 Benefits of Leveraging Third-Party Administrators in the Business of Healthcare

A Third-Party Administrator (TPA) is an agency or company that provides administrative services related to healthcare benefits on behalf of insurance companies, employers, or other organizations. They act as an intermediary between the insurance company or employer and the healthcare providers and patients.

One of the primary functions of a TPA is to process and manage claims for insurance companies. This includes reviewing claims for accuracy and eligibility, paying claims promptly, and handling any appeals or disputes that may arise. By utilizing Third-Party Administrator for claims processing, healthcare organizations can reduce their administrative workload and ensure that claims are processed accurately and efficiently.

TPAs also provide support in network management. They work with healthcare provider networks to negotiate contracts and rates, monitor provider performance, and help organizations ensure that their employees or members have access to high-quality healthcare providers. Additionally, they offer consulting services to help organizations design and manage their self-insured plans effectively. This can include analyzing claims data to identify cost savings opportunities, providing guidance on plan design and compliance, and helping organizations navigate the complex regulatory landscape of the healthcare industry.

What Does a TPA do?

Medicare Advantage Health Plans offer additional benefits like dental, vision and hearing coverage that traditional Medicare doesn't cover. Private insurance companies offer these plans, but TPAs play a crucial role in managing them.

Claims Processing & Payment Administration

• TPAs handle the end-to-end claims lifecycle, from verifying eligibility to adjudicating and reimbursing claims.
• They ensure timely and accurate claims processing while detecting and preventing fraud, waste, and abuse (FWA) to minimize financial losses.
• TPAs ensure that payments align with Centers for Medicare & Medicaid Services (CMS) regulations and contractual agreements with providers. 

Also read, How to Boost Member Satisfaction with Claims Processing

Member Eligibility & Benefit Management

• TPAs verify Medicare eligibility based on CMS data and ensure members receive the appropriate benefits under their plan.
• They customize plan designs, including provider networks, co-pays, deductibles, and drug formularies, to meet the specific needs of the member population.
• They help administer special needs plans (SNPs) for members with chronic conditions or institutionalized care needs. 

Also, read 5 reasons for Outsourcing Medicare Enrollment

Provider Network & Contracting Support

• TPAs negotiate and manage provider contracts, ensuring that healthcare services are delivered at cost-effective rates.
• They facilitate provider credentialing and compliance, ensuring healthcare professionals meet CMS and state regulatory standards. 

Also, read Pros and Cons Of Running A Physician Network In Today's World

Regulatory Compliance & Reporting

TPAs ensure that Medicare Advantage plans comply with federal laws such as:

• ERISA (Employee Retirement Income Security Act) regulates employer-sponsored benefits, ensuring fiduciary responsibility.
• HIPAA (Health Insurance Portability and Accountability Act) safeguards patient data privacy and security.
• CMS Medicare Advantage regulations include risk adjustment, star ratings, and beneficiary protections.
• They assist in preparing required reports and audits for CMS to maintain program integrity and avoid penalties.

Cost Management & Risk Adjustment

• TPAs help control costs through utilization management (UM), care coordination, and disease management programs to prevent unnecessary hospitalizations and ER visits.
• They leverage risk adjustment analytics to ensure proper reimbursement by accurately documenting member health conditions.
• TPAs identify high-risk members and facilitate interventions through chronic care management and case management programs. 

Also, read Utilization Management's Impact on Healthcare Organizations

Member Engagement & Communication

• TPAs manage member education and outreach programs to ensure beneficiaries understand their coverage, benefits, and wellness programs.
• They provide customer service support, handling grievances, appeals, and enrollment-related inquiries.
• By offering digital tools (portals, mobile apps, telehealth integration), TPAs enhance member engagement and satisfaction.

Get CMS-Validated Enrollment with 95%+ Efficiency.

Benefits of Outsourcing to a TPA

Partnering with a trusted TPA for healthcare can have several benefits, including:

Improved Efficiency

TPAs can streamline administrative tasks such as claims processing, eligibility verification, and member enrollment. This can reduce the administrative burden on employers and insurers and free up resources to focus on core business activities.

Specialized Expertise

TPAs specialize in healthcare administration and have extensive knowledge of healthcare laws and regulations. They can help ensure compliance with these laws and regulations, reduce errors and omissions, and mitigate risks.

Customization

TPAs can tailor healthcare benefits to meet the unique needs of each employer or insurer. This can help ensure that healthcare benefits align with the employer's overall business strategy and goals.

Outsourcing administrative tasks to a third-party administrator can be a smart decision for organizations that want to streamline their functions and save on time and resources. However, it’s important to choose a reputable and reliable TPA that has a proven track record of success.

Key Considerations When Choosing a Third-Party Administrator

Selecting the right TPA is a critical decision that can significantly impact the success of your healthcare benefits program. Here are some key factors to consider during the evaluation process:

• Experience and Reputation: Look for a TPA with a proven track record of success and positive client testimonials. Consider their experience in your specific industry or with organizations of your size and complexity.
• Service Offerings and Customization: Ensure the TPA offers the specific services you need, from claims processing and network management to more advanced capabilities like data analytics and value-based care support. They should also be flexible and able to customize their services to meet your unique requirements.
• Technology and Infrastructure: Evaluate the TPA's technology platform. Is it user-friendly, secure, and capable of integrating with your existing systems? Do they offer online portals for employers, employees, and providers?
• Compliance Expertise: Healthcare regulations are complex and constantly evolving. Choose a TPA with deep expertise in relevant laws like ERISA, HIPAA, and any state-specific regulations. They should have robust compliance programs and procedures in place.
• Network Access and Management: Understand the TPA's network capabilities. Do they have access to a broad and high-quality provider network that meets the needs of your employees or members? How do they manage network performance and negotiate rates?
• Customer Service and Support: Evaluate the TPA's commitment to customer service. Are they responsive, accessible, and dedicated to providing excellent support to both your organization and your employees or members?
• Security and Data Privacy: Inquire about the TPA's security protocols and data privacy practices to ensure the protection of sensitive patient information.

By carefully considering these factors, healthcare organizations can make an informed decision and choose a TPA that aligns with their goals and helps them effectively manage their healthcare benefits.

Get Scalable & Compliant TPA Solutions with Medicare Advantage In a Box.

Why Choose Mirra Health Care as Your Third-Party Administrator?

Mirra Health Care is deeply committed to providing high quality, low cost, easy to use, technology driven products and services for Medicare Advantage Health Plans, providers and patients. Their services can enable the following:

• Automate creation and fulfillment of all member correspondence including ANOC, letters, Welcome Kit, ID Card, HRA and more.
• Auto-update invoices for all retroactivity related to CMS enrollment each day.
• Provide a single platform to process medical, institutional, dental and capitation claims.
• Create RAPS files from encounter data submitted to EDPS.
• Provide a real-time global view of authorization and outstanding requests from multiple sources.
• Enable providers to search and view claim details submitted for their TIN/NPI, including EOP’s from the claim adjudication system.
• Handle separate workflows for applicants, members, members representatives, providers, agents and prospects.
• Include all required CMS Reports including Part C, Part D and Universe Reports.
• Process claims through accurate member information updated through integration with the enrollment system.
• Solve routine needs in real time by getting accurate information from dependent systems.

Conclusion 

Outsourcing to a Third-Party Administrator (TPA) offers a strategic advantage for healthcare organizations looking to enhance operational efficiency, reduce costs, and maintain compliance with ever-evolving regulations.

TPAs bring specialized expertise in claims processing, provider network management, and member engagement, helping organizations streamline administrative tasks while focusing on delivering quality care. By leveraging advanced technology and industry best practices, TPAs ensure accuracy, mitigate risks and better financial performance. 

At Mirra Health Care, we provide end-to-end solutions designed to support Medicare Advantage Health Plans with Medicare in a Box. Our expertise in claims processing, compliance, and provider management ensures seamless healthcare administration, allowing organizations to focus on delivering high-quality care while reducing operational tasks.

Reference 
https://collectivehealth.com/blog/benefits-shop-talk/what-is-tpa-insurance/