The Issue is Two-Fold
As a third-party administrator (TPA), you are already well aware of the many challenges that you have to navigate with EOB processing. Those responsibilities and difficulties start at a high industry level and work their way down to more granular, business-specific workflow challenges. And while some are easier and more quickly solved than others, they all factor into overall TPA inefficiency across the country.
While some TPAs are further along in their efforts to streamline their processes and the tools they use in them, many others aren’t. Here, we’d like to explore two specific reasons for this — and how technology can help provide a solution for both.
1. TPAs Are Still Using Manual Processes for Critical Functions
As the American population continues to age (by 2020, people 65 and older will outnumber children under 5) and more people continue working longer (one-quarter of Americans plan to work beyond their 65th birthday), the number of claims will only increase. While not all will have medical expenses that need reimbursement, this nonetheless means the workload coming your way as TPA is only going to increase.
Despite the availability of numerous software systems that can automate many core business functions, many TPAs are still using manual processes to manage their medical claims workloads. These range from unsafe and wasteful paper-based workflows to inefficient and time-consuming emails and spreadsheets. Even though the latter are electronic, both manual processes can still result in important information being lost.
Much of this TPA inefficiency actually rests on plan members, too. Requiring plan members to obtain, scan, email, or even fax their EOBs to you can quickly confuse those who might not be as savvy or experienced with the process. The plan member might not fully understand what they need to provide or might send over the wrong information. And it’s all on their timetable. They might not be able to submit additional documentation that you need for substantiation until the evening or even the weekend depending on their personal life schedules, which means your team is left waiting while their workload is increasing.
Once received, you still have to substantiate the EOB — an equally time-consuming process as many insurance carriers don’t integrate directly with TPAs, creating more work for you and your team. And that’s just with EOBs themselves — plan member enrollment is an additional project that can produce just as much manual work without a proper solution.
Technology addresses this TPA inefficiency simply by automating as much of these core business tasks as possible. While it might not seem like an issue to have your team answering emails or gathering scanned or faxed documentation, each of these tasks takes time. That time multiplied by the number of claims can quickly add up. Even the minute it can take to open and read an email from a plan member and download a PDF of their EOB can quickly turn into hours upon hours of lost time — and revenue.
2. The Healthcare Industry Itself Impacts TPA Inefficiency
The U.S. healthcare system is grossly inefficient compared to the health systems of other developed countries. Our system spends almost double the amount on healthcare and invests significantly more time navigating and completing various administrative tasks. This isn’t breaking news — in fact, it’s been an issue for some time. Healthcare workers have huge amounts of information that must be both referenced for reimbursement.
Medicare and private insurance companies also have their own rules and processes when it comes to billing procedures, what kinds of documentation are required, and how those documents are submitted. There are numerous policies and private insurance companies, too, which is far more than any person can navigate and remember on his or her own.
While we may not be able to change the system ourselves, what is needed to help you resolve TPA inefficiency is again automation. If you couple the vast amount of documentation, reference material and coding, and insurance-specific procedures with manual processes, it will be extremely difficult — if not impossible — for you and your team to keep up with your current workload, let alone any future changes or claim surges, such as year-end.
Use a System Built Specifically for You to Resolve TPA Inefficiency
There are many platforms available that can help you automate and streamline a variety of functions at your TPA. At TPA Stream, we’ve spent years building an industry-leading integration platform that brings many of your most important functions together into a single platform. From EOB processing to billing, our platform can help your team get back to doing what they do best: providing fast service to plan members, keeping employers happy, and bringing brokers back to you for new business.
Ready to learn how TPA Stream can solve your most burdensome administrative challenges? Sign up for a demo today.