Third Party Administration Services
Enrollments and the related costs have dramatically increased due to healthcare reform. Reform has expanded eligibility and access to millions of new Americans through new vehicles such as healthcare insurance exchanges (HIX) and through regional CO-OPs. In order for these health plans to be successful, they must contain costs while being efficient and improving outcomes over their rivals.
As the healthcare environment continues to evolve, health plans and the programs they serve will be graded and rewarded based on improvements to the member's health status. We have over 40 years of experience providing services to health plans of all shapes and sizes. Our third-party administration (TPA) services give health plans and CO-OPs the flexibility to do more for their members while reaping significant financial dividends under the right operating structure.
Our core TPA services include:
- Plan administration and system operations: from enrolling new members to processing their claims
- Omni-channel communication: capabilities include member and provider contact centers, outbound mailing, electronic document delivery (eDelivery) and compliance with the summary of benefits and coverage (SBC) mandate
- Integrated care management: quality management and utilization review
- Cost avoidance and recovery services: including a full spectrum of fraud, waste and abuse detection and prevention solutions
- Financial management: billing, payment processing and reconciliation
- Credentialing and contracting
Additional TPA services that can be integrated include:
- Plan design
- Electronic data interchange (EDI)
- Long-term care management
- Provider relations management
- Analytics and reporting
- PBM services
Our TPA services give health plans and CO-OPs the ability to rapidly scale so they can meet the demands of healthcare reform, allowing them to focus on providing better services to their members and utilize reform as an opportunity to grow their business.
Download CO-OP Services Overview (PDF, 827 KB)