Third party administrators are an essential part of the health insurance ecosystem, but they also create some challenges when it comes to understanding the pricing structure for member organizations. With the No Surprises Act now in effect, pricing transparency is essential. In this article, originally published on Future Healthcare Today, takes a look at the space and explores how being able to differentiate and be more transparent will become a distinct advantage for third party administrators.
“If you’ve met one third party administrator (TPA), you’ve met only one TPA. Every one is very unique and specializes in different lines of business,” said Dennis J. Charland, Senior Vice President of Sales at Sapphire Digital. In the distinctive space of TPAs, the number of partners impacts network structures, in turn, making it challenging to reflect pricing to members. This will become a substantial roadblock to meeting requirements as provisions of the new laws go into effect.
Charland commented on how this is “an opportunity for TPAs to differentiate themselves. It helps give them the opportunity to meet the demands of digital adoption, which increased significantly due to COVID-19.” Solutions can provide tools that help members with their decision process about what care they would like to receive. According to Charland, digital adoptions have more than doubled across the entire healthcare industry since the pandemic began, including telehealth services. Digital tools give TPAs a unique value proposition with employer groups that hope to influence member decisions and improve member engagement.
While the tools are available for self-service to members, they can also be supported telephonically through the TPAs member service team. TPAs are easily able to shop on behalf of their members. This service is beneficial in situations where the member is new to healthcare shopping. Charland provides the example of a member seeing an $800 colonoscopy next to a $2,000 one. With this solution, the TPA can talk through the options with the member, give advice based on other patient experiences, and provide data points to aid their decision. Generally, individuals will assume “higher cost equals higher quality,” but, in reality, this is often not true. Increased digital transparency provides patients with all the information they need in order to make an informed decision.
One of the key differentiators for TPAs is being able to offer end-to-end support. By integrating vendors, TPAs can better differentiate themselves, provide for their clients’ members and offer more cost-saving services and innovative solutions such as bill review, claim negotiations, and market-based pricing.
A comprehensive solution suite can drive choice and cost savings for TPAs and give them a competitive edge in the coming year. Innovative solutions provide the opportunity to optimize network performance, increase pre-payment optimization efficiency, control the payments process from the beginning, and engage members with clear enrollment, cost, and claims communications.
To learn more about compliance solutions for third-party administrators, click here.