As the pivotal link between insurance carriers and policyholders, third-party administrators (TPAs) serve a critical function in today’s healthcare value chains. In this capacity, TPAs shoulder much of the burden when it comes to managed healthcare system processes and health insurance claims management and reimbursement; unfortunately, today’s intricate healthcare insurance landscape can make handling claims processing for employers a complicated and inefficient endeavor.
In this article, we’ll explore some key challenges TPAs face in the increasingly competitive and complex insurance landscape, and how Ventiv Technology’s’ solution suite helps streamline claims management and administration, enabling TPAs to realize significant cost savings and operational efficiencies.
The Evolving Role of TPAs
TPAs traditionally handle claims processing for employers that provide insurance to their employees, as well as other aspects of the employee’s benefit plans. Partnering with the right TPA also helps insurance carriers scale, realize new cost synergies and accelerate their own automation and digital enablement goals. For this reason, insurance firms commonly outsource their claims to TPAs, which leaves the TPAs responsible for customer service and support.
In this sense, the role of the TPA is transformational for all parties in the insurance value chain. Because of their key function, TPAs often require substantial digital transformation, automation capabilities, robust processes, and scaling capabilities to help insurers meet the expectations of current and future customers.
Challenges Faced By TPAs Today
In performing this critical role, TPAs face several key challenges in the evolving insurance value chain related to scalability, compliance, and automation.
According to PropertyCasualty 360, the combination of pandemic disruptions, the Great Resignation, and an aging insurance workforce have resulted in the insurance industry’s current historic labor shortage. Especially a shortage of experienced claims adjusters.
The adjuster shortage has stifled insurance firms’ ability to scale in the face of increasing claim volumes and customers’ expectations. Carriers must effectively “do more with less”—they must improve their existing claims adjusters’ efficiency and enhance the customer’s experience, even as they face talent shortages. These bottlenecks and shortcomings have a direct impact on the ability of TPAs to render timely and efficient claims management services downstream.
Over the past few years, the insurance sector has experienced an uptick in compliance-related incidents—this is not surprising, as compliance efforts are often complex, labor-intensive, and driven by manual efforts. This complexity is exacerbated by continuously evolving local, state, and federal compliance mandates. For example, the recent passing of the Medicare and SCHIP Extension Act (MMSEA) places new mandatory reporting requirements on group health plans that provide coverage to Medicare beneficiaries.
Today and tomorrow’s competitive insurance landscape and complex operating environments mean that insurance carriers and TPAs must increasingly adopt low-touch or touchless claims for low-complexity claims. Unfortunately, existing claims management solutions are unable to support claims automation, have laborious workflows and processes, and lack user-driven business rules.
By moving to straight-through processing (STP), insurance carriers and TPAs can reduce the duration required to process claims. And with low-complexity claims automatically handled by a claims management software as a service (SaaS), their adjusters can focus on more complex claims and higher value, strategic tasks.
How Ventiv Helps TPAs Improve Cost Efficiency
Ventiv Technology’s claims management solution helps TPAs and insurance firms manage the industry’s growing complexities—both in terms of the regulatory landscape and compliance requirements, as well as shifting demands in an evolving business environment. For example, Ventiv’s solution features a myriad of built-in features for streamlining insurance workflows as well as comprehensive compliance to support existing and future regulatory requirements.
With all of these tools unified in a single claims management software as a service solution, Ventiv allows TPAs and insurance carriers to reduce the likelihood of incurring penalties and fees.
Along with its robust tools for maintaining compliance, Ventiv’s claim management software features built-in security and fraud prevention controls like a completely configurable in-product security layer, data encryption at rest and in transit, as well as full integration with ISO Claims Search—the property/casualty insurance industry's first resource for evaluating claimants' claims histories and detecting claims fraud. Last but not least, as an independent attestation of its security posture, Ventiv’s claim management SaaS is SOC 2 compliant.
Tangible Cost Savings
By providing a single touchpoint for compliance needs, Ventiv lowers insurance carrier and TPAs’ compliance costs by eliminating third-party transaction fees, resulting in an estimated cost savings of more than $200,000 per year, for every 5000 claims processed. And by introducing configurable workflows to support business processes without the need for manual intervention, Ventiv’s claims management software improves claims adjuster productivity and allows for more advanced analysis and triage—for example, the solution’s business rules coupled with analytic models allow for early intervention on potentially high-severity claims.
By providing these STP functions for low complexity claims, Ventiv can save TPAs and insurance carriers over $100,000 per year, as well as help them improve cost efficiencies by up to 20%.
Ventiv’s solution enables insurance carriers and TPAs to streamline and automate their claims management processes, scale their user bases quickly, and eliminate IT overhead and the need for on-premises infrastructure—all without compromising security or compliance. The final result is fully realized STP, better compliance, enhanced customer satisfaction, and overall lower claims costs.
Chat with an expert today and find out why Ventiv’s claims management solution is the right solution for your organization.