Top 15 Questions to Ask Your Third Party Administrator (TPA)

Choosing a provider, third party administrator
1. Which services do you provide in house and which do you outsource?

With multiple providers involved, it is important to confirm the TPA’s privacy policy, as well as if any outside service provider is being used so they can be evaluated as well. Accurate claims decisions on disputes and rapid claims turnaround are key to both cost and employee satisfaction. Some TPAs offer primarily eligibility and premium administration, with other aspects like claim payment and issuance of drug cards outsourced.

2. Are you free to choose any insurance carrier or are you tied to a set carrier?

Some TPAs enter into exclusive arrangements with one insurance carrier, while others have professional TPA relationships with an an array of providers, which can offer greater flexibility with rates and coverage.

3. Do you work with independent insurance brokers?

Business owners often have an established and trusted relationship with an independent advisor because they value impartial advice. A good working relationship between the TPA and independent brokers indicates a high level of customer service and proven service delivery.

4. Is your customer support staff trained and able to solve problems on a client’s behalf efficiently and quickly?

Ask about the TPA’s policies and procedures regarding decision making, problem resolution and live phone or chat features available to you. The last thing you want when you or your employees call for help with a plan question or issue is to be passed around or lost in an automated system.

5. Do you provide a written agreement that outlines all financial terms, services, and fees?

A financial agreement is key to ensuring that all parties are aware of their responsibilities. This agreement will also specify when benefits plan costs could be changed, and on what basis the agreement could be terminated.

6. Can you provide me with your privacy policy?

TPAs will handle extremely delicate information. It is imperative that they protect your information in order to comply with federal and provincial legislation.

7. How do you detect claims fraud?

When interviewing a TPA be sure to ask these questions, they will help to detect fraud, which is essential component to administrating your group benefits plan.

  • Do you have a documented fraud policy?
  • Are you a member of CHCAA (Canadian Health Care Anti-Fraud Association)?
  • Are your adjudicators trained to identify potentially fraudulent claim expenses and claiming patterns?
  • In instances of potential fraud or plan abuse, what is your escalation process?

8. What is your financial reporting and breakdown of claims structure?

It is important to assess your funding surplus/deficit position, which will allow you to make adjustment decisions quickly if necessary. Certain TPAs will provide monthly financial statements to confirm the status of your account with a breakdown of claims paid by type of claim

9. Do you carry Errors and Omissions (E&O) and Director’s Liability Insurance?

Ask a prospective TPA for a copy of the insurance certificate to be included in their proposal.

10. How long have you been in business as a TPA?

With all the technological advancements many small TPAs have opened their doors and some offer services at discounted prices, but if what they’re offering seems too good to be true, it usually is! A full-service TPA will have a robust business presence with the reputation in the marketplace to back their reputation. You or your advisor should do some careful research.

11. Can you provide references?

An experienced TPA should provide you with business references that are recent, established and relevant . Ask to speak to a mix of recently added clients and mid-long term clients that are similar to your business.

12. What services are included in your administration fees?

When comparing TPA fees, it is important to understand if your administration costs may be impacted by other charges, such as separate per-claim fees or other service fees in addition to your agreed upon standard fees. A full service TPA should offer accurate claims adjudication, financial accounting and reporting, tax remittances, and adherence to CRA regulations.

13. Do you produce Drug Cards and Employee Booklets in-house?

Outsourcing the production of drug cards and booklets can lead to delayed turnaround on new cards and replacement card requests. Handling these matters in house allows for more efficiency and faster replacement times, which means less hassle for you and your employees.

14. Are you independently audited?

A full-service TPA will be managing significant funds on your behalf. It is important that the TPAs financial processes are independently audited to verify accuracy and adherence to industry requirements and laws. Find out whom the audits are done by and how often, this will help to ensure that your funds are held in trust.

15. Do you offer budgeted ASO plans?

Budgeted ASO plans will allow for stable cash flow which is particularly important for small and mid-sized businesses. Under a budgeted ASO plan, fluctuating claims will not jeopardize the financial stability of your plan.

*Bonus Question* 16. Are your members restricted to a preferred network?

Some TPAs restrict their members to certain networks of health care service providers such as dentists, physiotherapists, etc. Find out if their plans are open or restricted, you can then decide how much flexibility is important to you and your employees.

Are you currently searching for a Third Party Administrator in Ontario? If so, we encourage you to talk to your Employee Benefits Advisor about how to choose the right TPA.

We can also recommend an experienced advisor in your area.

About Karen Taylor Smith

Karen Taylor Smith is the Senior Manager, Group Benefits at The Benefits Trust. She has worked with The Benefits Trust since 1997, using her deep knowledge of employee benefit plans to customize the right solutions for businesses. Karen speaks, blogs, and contributes regularly to various media outlets on group benefits and compensation topics.

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