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Processing Claims Made Simple for TPAs with Automation

TPAs are stuck in a web of manual claims tasks that lack efficiency. Automation can help. Learn the 4 steps TPAs need to take before they can process claims more efficiently with automation.


As a Third-Party Administrator (TPA), you’re pulled in a lot of directions.

Your first objective is to support your clients by processing claims and improving their claims’ outcomes.

Next, and maybe even most importantly, you are face-to-face with the end-user, or the claimants and their families on a daily basis, with the goal of moving their claims through your internal process — quickly. The communication necessary to do this successfully assumes an extra layer of complexity when your service is white-labeled, requiring different client-facing language and policies.

And, if the business’ broker was your referral partner, then you’ve got to keep them happy, too, so that you’re top of mind when they’re brokering their next deal.

Although very different, these three disparate parties — together with you, the TPA —have the same ultimate goal: to process claims efficiently.

Sounds simple, right? Unfortunately, more often than not, processing claims efficiently is anything but simple.


Employing automation to create efficiency in processing claims

The claims process, when done manually, is haphazard at best. Much of your days are spent retrieving and attaching PDFs to and from emails, sending information via fax, forwarding on notifications and pulling data from numerous places to create reports and move claims onto the next stage.

Whether you’re working in spreadsheets or a slightly more user-friendly reporting program, chances are the process you’re using to move claims to resolution is still highly inefficient.

Imagine if you could automate the entire claims process, streamlining manual work by creating a single process for document management that allows you to attach files directly to claims and move them through to resolution, 100% digitally?

The good news is you can – by engaging automation.

But, before you can automate your claims process, you’ve got to get your back-of-house in order.


A weak process is still weak even when it’s automated

Adding automation to a weak process won’t make it any stronger. In fact, it’ll just further systematize the weakness.

Before you upgrade to an automated process, it’s critical to get all your ducks in order by building a robust infrastructure that can support automation. When you make the leap, having the back-end work done ahead of time will make all the difference.

Here are the 4 critical steps necessary to get your TPA business ready to implement claims automation across your business.

  1. Audit existing workflows. Start by reviewing your existing processes and workflows. Map out who does what, from start to finish. How does the information get from the initial claim to final resolution, including every other step in between? Make sure to include all key stakeholders across the organization and their interaction with a claim so that every part of the process is documented. This is critical because very often, the claims team has specific ways of doing things and touchpoints with a claim that no one realizes until it comes time to name them. Naming every small and large touchpoint with the claim in this first stage is critical to being able to properly configure the automation system when the time comes.

  2. Identify dead ends. Once the current process and all its inefficiencies have been documented, it’s time to hold a magnifying glass up to each map marker and analyze it. Where are the dead ends and bottlenecks embedded in the existing process? Why do they occur? Think: Employee turnover, end-user actions or inactions, manual vs. digital workflow, long-term process inefficiencies that were never updated, carrier or employee requirements, etc.

  3. Dream big. Workflows have been mapped and dead ends have been accounted for. Now, it’s time to dream up what you want to get out of the claims automation process. At each map marker, discuss how technology could potentially optimize the workflow. Think about the trifecta of parties you are beholden to, i.e. the end-user or claimant, the client, the carrier and the value automation can provide to them as well. Determine what you want the automation to look like, how it will close up the gaps left open by your old manual process and how it will play out when it comes to individual workflows.

  4. Create a personalized automation plan and go live! Here’s where you dig in deep to create the workflow within the automation system itself to align it with the way your staff currently works. Create a realistic action plan and timeline for implementation, based on your business goals and the problems identified earlier. Name a champion in the office to lead the implementation and direct all inquiries to this person to streamline the process. Involve all stakeholders in this part of the process so there’s buy-in at all levels ahead of the implementation start date. When possible within the automation system, consider how you want to customize reporting, analytics and compliance tools. Create individual rules for incident notification, audits and field assessments. Design off-line rules and processes to align with the automation system’s claims intake, notification and adjuster reporting capabilities.

Bridging the gap from manual to automated isn’t easy. It takes time, a team of dedicated individuals and a period of trial and error optimization. The challenge for TPAs will be twofold. One, trying to maintain an existing workload while overhauling the very claims management system you’re working in simultaneously. And two, doing so while keeping employees, clients and carriers happy.

And yet, we all know that process improvements only come from dedication and the willingness to do and see things differently in the name of efficiency, productivity and optimal outcomes.


Next Steps

For more information on automating your claims management program with claims management software, contact Leslie Sargent, Ventiv’s TPA practice leader.

Learn how Tribal First, the largest provider of insurance solutions to Native American Tribal Nations, automated their claims process.Ventiv-3SIXTY-TribalFirst


Dec 17, 2020

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