TPA & Employee Benefit Systems

The introduction of Third Party Administrator (TPA) in insurance sector came as a blessing in disguise for insurance companies and policy holders. In recent times, we have seen a lot of innovation on products side and service side and TPA is considered as the best innovation on service front.

A TPA is a legal entity which acts as an intermediary between insurance companies, customers, regulatory body and healthcare providers. Knowing the demand and supply side complexities in health insurance and healthcare markets, TPAs provides an important linkage between insurance companies, healthcare providers, and policyholders. In other words, TPA’s can be termed as a BPO for insurance companies. It performs various benefit administration and claims processing services for other organizations. TPA’s function in a number role for insurance company where the main motto is to provide better service to customers and help the insurers in cutting down on operating costs. Health insurance companies generally tie up with TPAs for the back office function of managing claims and reimbursements.

In short, TPA exists to administer all the health care functions for a company that would have been handled by insurance company’s in-house employees.

TPAs provide major support to Health Insurance, Employee Benefits, Auto Insurance, Workers Compensation Insurance and Long Term Care Insurance. The main functions of TPA’s is to provide cashless service to customers, hassle free claims settlement and value added services like arranging ambulance services, medicines and supplies, guiding policy holders for specialized consultation, and providing information about 24- hour help lines, health facilities, bed availability, organization of lifestyle management and well- being programs.

Some of the main points around TPAs which is a cause of concern in the market scenario are as follows:
  • Firstly, there is service related concern like queries going unattended, processing errors, work backlogs, lack of service innovation, etc.
  • Then we have financial and regulatory concerns like fee increase, regulatory compliance and insufficient compliance efforts.
  • Lastly, reporting and technology concern is also equally important. Some of examples are mistakes in reports, delays in providing actuarial data, failure of creating ad hoc reports, over dependence on manual processes, etc.
How we can help you?? can serve clients in the following way:

Apart from the above mentioned general services TPA’s also provide services to the corporate sector in designing and managing health benefit packages for their employees.

Why for TPA Services?
  • A full array of reports, including in-depth analysis of claims
  • Case management services for long-term care, high-risk maternity and other special needs
  • Client-centric focus with dedicated, cross-functional teams
  • Comprehensive benefits management to control claims costs, cash flow and risk
  • Consultative, collaborative approach to ensure superior benefits value and performance
  • Exceptional medical management program integrated with disease management, decision support, and predictive modeling disciplines
  • Financial strength and technical resources that provide security, integrity and flexibility
  • Flexibility to accommodate unique benefit designs and administration
  • Individualized network performance monitoring
  • Peer review performed by physicians and ancillary providers in each community to determine appropriateness of care
  • Regular credentialing of all providers
  • Specialized health benefits solutions based on new ideas, best practices, and aggressive cost­-management strategies
  • State-of-the-art data warehouse and reports to give clients actionable benefits program performance information
  • State-of-the-art Management Information Systems, enabling timely and efficient eligible claims administration
Superior utilization management overseen by physicians, ensuring that only necessary and appropriate ambulatory services and hospital care is approved

425 Washington Blvd., Jersey City,
New Jersey 07302, USA

Phone: +1 201.258.4704 / 201.258.4704
Fax: +1 201.604.3480