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TPA's for small groups


Guest parrot87

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Guest parrot87

This is a TPA question for the 50-100 employee groups. Does anyone know of any good TPA's that go down to 50 lives & operates in the Philadelphia area?

Thanks

edited for clarity

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In my experience, a short list of TPAs is one of the first things done in order to evaluate the merits of self-insuring a Plan. How did you decide on the merits without knowing the costs and processes involved ?

George D. Burns

Cost Reduction Strategies

Burns and Associates, Inc

www.costreductionstrategies.com(under construction)

www.employeebenefitsstrategies.com(under construction)

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Guest parrot87
In my experience, a short list of TPAs is one of the first things done in order to evaluate the merits of self-insuring a Plan. How did you decide on the merits without knowing the costs and processes involved ?

Thats why I asked the question.

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You apparently misunderstand my post or do not understand what I am saying.

You should not be at the stage of having already found stop-loss carriers BEFORE finding TPAs and completing other steps.

In other words you should not be asking your question at this stage.

George D. Burns

Cost Reduction Strategies

Burns and Associates, Inc

www.costreductionstrategies.com(under construction)

www.employeebenefitsstrategies.com(under construction)

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Guest parrot87

OK, I understand. You're right. I sent out a blast email via google for stop loss and tpas. stop loss got back to me, tpa's that will do the 50-100 market did not. That said, does anyone know of any TPA's that will enter the 50-100 market in the philadelphia area? I'm guessing they would have to have a certain arrangement with Independence Blue Cross due to their discounts. Anyway, any names would be helpful.

Thanks

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A claims administrator might or might not have an arrangement with Independence BC. They usually have discount arrangements with PPOs, which Independence might or might not offer to them, assuming that Independence does have its own network rather than "leasing" an existing network.

Most, if not all, the large insurance carriers offer ASO contracts which is another reasonn why there might be no arrangement with TPAs for self-funded groups.

So you have a choice of any large insurance carrier, Great-West, many benefits consulting firms and most cafeteria plan administrators. Geographic location is usually irrelevant. Since few are listed with BenefitsLink as service providers, it would be unethical to give you names.

IMHO, you probably got no responses because no one thought that you were serious. They probably don't see many people who put the cart before the horse, if your OP is any indication of how you might have worded that email.

George D. Burns

Cost Reduction Strategies

Burns and Associates, Inc

www.costreductionstrategies.com(under construction)

www.employeebenefitsstrategies.com(under construction)

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Matthew

Just as you sought help here, and I hope that we were helpful, others also are seeking help. It is only fair that you share what you can so as to help others.

George D. Burns

Cost Reduction Strategies

Burns and Associates, Inc

www.costreductionstrategies.com(under construction)

www.employeebenefitsstrategies.com(under construction)

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Guest parrot87
What is it that you want the TPA to do?

All the normal stuff that a tpa does, could you specify your question?

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Matthew

No need to get uppity. It is a valid question and one that should have been one of the first responses.

In a normal situation someone with your issue would usually look for the TPA first. That you put the cart before the horse does not make the question questionable. IMHO, it is you who should be more specific.

George D. Burns

Cost Reduction Strategies

Burns and Associates, Inc

www.costreductionstrategies.com(under construction)

www.employeebenefitsstrategies.com(under construction)

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Guest parrot87

Didn't know I was being uppity, sorry George. I"ll tell the whole story if you need it to be satisfied.

I'm looking for a market for employers with 50-100 employees who want to limited self fund. So I went on google and typed in tpa's and filled in all those lead generation sheets and did the same for stop loss. A few companies called me up based on the information I provided via the web, they were stop loss insurers. TPA's did not call back, not one. So I came here to see if there were any in the Philadelphia area. I understand the criticism, maybe I should of looked for the TPA first and made sure that there was a good one there. But I decided to look for both simultaneously via the web since well it would only take a few extra seconds to fill out the questionnaire online. I didn't know that this was such a bad idea, I'm still not exactly sure why it was a bad idea since I know I needed both to see if this was even a possibility for this market size.

This was a serious inquiry for a lumber mill company based out of southern NJ with ~75 employees on the medical plan. I asked for specifics names. As for the cart before the horse, I asked for the cart and the horse at the same time. The cart showed up first so I asked if anyone knew if there was a horse around.

As for determining the merits of self funding without knowing the costs & processes involved, maybe you could point me to someone who would do a feasibility study for this group. The group does not have any experience information. Their demographic is mostly young men. Like I said before, the group is based out of southern NJ.

If you would like information for help or education, please ask, if you would like to scold me for not doing something correctly, please let me know how I could have done it better in this particular circumstance via private message. I've found a few TPA's that will work for this group since my original post.

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I have no ideaa what you could mean by "limited self-fund".

There are small employers who are interested in self-funding even for a few years.

There are small employers who wuld just do it for the possible first year savings, then revert if need be.

However, to put together an offering and marketing material requires some knowledge of the subject and its many issues. I suggested that you do some research first but you seem to have decided against that.

I find it hard to believe that you d not detailed claims experience, but that could be because you do not know how to get it, which is one of the things that good TPAs are able to and do so as an early step usually as part of the feasibility, but you by-passed this.

I made some off the board suggestions of people to call and you said that you called afew What did Great-West say ? GW might very well be the largest TPA in the size that you are looking for and also makes available a lot of guidance material. Plus there is always Google.

George D. Burns

Cost Reduction Strategies

Burns and Associates, Inc

www.costreductionstrategies.com(under construction)

www.employeebenefitsstrategies.com(under construction)

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Guest parrot87

Mr. Burns, if you know how to get the claims experience, I'd be amazed. I used to work for the largest General Agent in Philadelphia for IBC (which has 80% market share) and they wouldn't release claims info to us for small groups (under 100 lives), and we were basically working for them. The only idea that I have to get the claims info is that you would have to have an (illegal) inside favor from someone who works at that particular carrier to access claims info for these small groups and send them to you. Please tell me how I would get this claims info legally?

The TPA's that do small groups will rate without claims info, they rate demographically. They can't do a feasibility study because of the lack of claims info. That is up to the consultant. Great West does it this way as well. The TPA's (including Great West, i.e. CIGNA) could not get the claims info. You seem to be adamant that claims info is easily accessible if one "knows what they're doing", whats the next step if the carrier will not release them and the TPA cannot get it?

Why do you think I haven't done my research? I went on your urging and brought up the subject that "as a good TPA, can you get the claims experience" and no, none of them can. The question itself is quite ludicrous if you've ever worked in the Philadelphia marketplace.

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While I usually work with large groups, I have had a few small ones. But it could depend on your legal stnding, purpose and your explanation of need and applicable law.

We get the info by having the employer/plan sponsor send a letter instructing that the info be provided to us for health plan purposes. The letter is sent certified RRR to the CEO. Anyone else seems to cause chaos. We have had to sometimes persist and insist, but have always got the info. In 1 case each in Indiana, RI, NJ and Mryland we had to have the state DOI make a call threatening action if the info was not provided. We did not have to make formal ccomplaints, just a simple phone call and then faxed the correspondence. In most states the issue falls under Unfair Business Practices.

There are some areas in the country where the data is just not very readily availabel because of how that regions Small group health rates are determined but even then a computer can sort out any individual by name or identifier. In the case of Indiana state law requires that data be kept on groups 2+lives.

I receive data from Great-West, Aetna, UHC, various BCBS, and a few small regional TPAs.

I have had groups with 20+, 30, 60 and 80 in Indiana, Ohio, NJ, Mass and Maryland.

I thing that I have successfully had close to 40 such requests made in the last few years.

I did do some work in 2002 to clean up an issue for some ex-clients of a PEO. All were under 100 lives and I think more than 10 were in the Philadelphia area and the others nearby in NJ. It was a self-funded plan through BCBS. I do not recall having any problems.

George D. Burns

Cost Reduction Strategies

Burns and Associates, Inc

www.costreductionstrategies.com(under construction)

www.employeebenefitsstrategies.com(under construction)

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Guest parrot87

I think you should double check your memory. It is illegal in PA (I believe NJ as well) for carriers to release claims data for small groups, simply for the fact they are not allowed to compile claims data for community rated groups (which any group under 50 is).

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I don't have to because I just recently received another check from a client for performing a particular claims review and reconciliation on a group of 32 lives in PA. Highmark is the insurer.

You might want to read the Pennsylvania Code 146b.11(b). This addresses privacy of health information in general. I do not have readily available their small group info or Unfair Business Practices info.

It is only illegal to use the individual claims experience to determine the premium rates for community rated groups.

Can you cite any statute or anything else in any state to support your statement ?

George D. Burns

Cost Reduction Strategies

Burns and Associates, Inc

www.costreductionstrategies.com(under construction)

www.employeebenefitsstrategies.com(under construction)

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Guest parrot87

That's the carriers policy. So you got past all the Highmark billing code problems? congrats.

P.S. - You may be correct about the claims info, but group claims info for small groups (not an individual in that group) is a different animal. Carriers use diagnosis codes not claims codes (for small groups), and the conversion to billing codes is different as well. I'll have to double check the legality of releasing small group claims info. Also, on a more personal note, if you knew this PA code to begin with, why didn't you just come forth with that information to begin with instead of trolling and harrassing?

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It is not the carriers policy, that was the Pennsylvania Code. They provide the info, not if they choose, they provide the info because the law says so.

Groups whether arge or small are made up of individuals. It is a simple merging of individuals that creates a group. Merging data is a simple computer operation.

I did not give an exact cite before (although I made reference more than once), simply because information such as applicable law would have been something that a rational person would have researched first before starting a discussion and argument. I made the assumption that you were rational and had some basic knowledge.

Carriers do not use diagnostic codes alone, they use diagnostic codes (ICD) AND procedure codes (CPT). Carriers are not the originators of claims they are the recipients. The initial coding is done by the claimant whether Dr, Pharmacy or other service provider.

What are "claims codes" ?

What are "billing codes" ?

There was no "billing code problem" to get past. As far as I know provider billing and claims adjudication has been standardized for years and everyone in each sector uses the same forms (used to be HCFA 1500 for Drs) and everyone uses the same ICD-9 and CPT-4 codes for billing and claims etc.

George D. Burns

Cost Reduction Strategies

Burns and Associates, Inc

www.costreductionstrategies.com(under construction)

www.employeebenefitsstrategies.com(under construction)

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