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Healthcare Payer Services

Third Party Administration Services

Enrollments and costs for health plans are expected to increase starting in 2014. Health reform expands 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.

In the evolving healthcare environment, 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.

Some of the primary third party administration services provided include:

  • End-to-end system operations: from enrolling new members to processing their claims
  • Customer communication: multi-channel capabilities that include member and provider call 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
  • Recovery services: a full spectrum of fraud, waste, and abuse detection and prevention
  • Financial management: billing, payment processing and reconciliation
  • Credentialing and contracting

Additional third party administration services that can be integrated include:

  • Plan design
  • Electronic data interchange (EDI)
  • Long-term care management
  • Provider relations management
  • Analytics and reporting
  • Underwriting
  • PBM services

Our TPA services give health plans the ability to rapidly scale so they can meet the uncertain demands of healthcare reform, allowing them to focus on providing better services to their members and use healthcare reform as an opportunity to grow their business.

Download CO-OP Services Overview (PDF, 827 KB)

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