All The Answers You Need About TPA
What is a Third Party Administrator (TPA) of a self-insured/self-funded medical plan?
A third-party administrator (TPA) is an organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity.This can be viewed as outsourcing the administration of the claims processing, since the TPA is performing a task traditionally handled by the company providing the insurance or the company itself. Often, in the case of insurance claims, a TPA handles the claims processing for an employer that self-insures its employees. Thus, the employer is acting as an insurance company and underwrites the risk. The risk of loss remains with the employer, and not with the TPA. An insurance company may also use a TPA to manage its claims processing, provider networks, utilization review, or membership functions.
What is a self-insured/self-funded medical plan?
Self-insurance describes a situation in which a person does not take out any third party insurance. The essence of the concept is that a business that is liable for some risk, such as health costs, chooses to "carry the risk" itself and not take out insurance through an insurance company.
The concept applies especially to health insurance and may involve, for example, an employer providing certain benefits – generally health benefits or disability benefits – to employees and funding claims from a specified pool of assets rather than through an insurance company, as the term is traditionally used. In self-funded health care, the employer ultimately retains the full risk of paying claims, in contrast to traditional insurance, where all risk is transferred to the insurer.
What is the Clinical/Health Audit?
Health or Clinical audit is a process that has been defined as "a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change".
The key component of clinical audit is that performance is reviewed (or/and audited) to ensure that what you should be doing is being done, and if not it provides a framework to enable improvements to be made.
Is a TPA solution right for me?
It depends on:
a) The number of your employees, plus their dependents (if any)
b) Their insurance eligibility
c) The cost of a premium based insurance contract.
Usually a minimum number of insured members should not be less than 400. But this is relevant to the cost of a premium insurance contract as well. In some Countries the cost of a premium based contract is so high, that allows self-insured plans with less than 400 insured members.
How Evrostia will implement my plan ?
Evrostia Financial Services will design the provided benefits and create the policy on behalf of the employer, after
creating an actuarial study in order to minimize the risk, based on;
Evrostia Financial Services own health claims' statistics
World Health Organization statistics and;
Taking into account the domestic conditions in health industry in the Country of the implementation of the plan.
Evrostia's high tech systems and bank assurance knowledge allows the
creation of an actuarial study in order to meet the specific health care needs of employer's workforce.
Evrostia Financial Services offers to its clients an operating mechanism of the TPA which functions
properly, and has a thorough follow up and management of the whole plan, using advance technology and specialised staff.
Evrostia Financial Service will provide your employees and their family members with an Evrostia ' Health
Card, which is recognized nationwide in over 30,000 accredited hospitals, doctors, etc. in Philippines, Russia, Ukraine, and in every hospital worldwide which accepts cards' payments.
The provided benefits under the policy, will be linked to our high tech work flow and no approval will be given before the
claim is checked by our Auditor Department. The members will have 24/7 high quality service through a "health line", and will be assisted by a medical escort and/or medical coordinator during their admission.
Is it possible to eliminate my insurance risk?
YES!! Evrostia is able to provide to its clients with an “Aggregate Stop-loss” insurance line, provided by "A' Rated Paper" insurance companies with Global presence. An “Aggregate Stop-loss” insurance line will cover the possible additional cost of your self-funded medical plan, if it exceeds a pre-agreed amount. Practically you self-fund your plan up to a pre-agreed amount, but you assign the medical expenses and the insurance risk to the insurance company, if the cost of your plan exceeds the pre-agreed amount.
What are my benefits, as employer, of a self-funded medical plan, under Evrostia's Administration?
There are several reasons why an employer chooses the self-insurance option under Evrostia's Administration. The following are the most common reasons:
The employer can customize the plan to meet the specific health care needs of its workforce, as opposed to purchasing a 'one-size-fits-all' insurance policy.
The employer maintains control over the health plan reserves, enabling maximization of interest income - income that would be otherwise generated by an insurance carrier through the investment of premium dollars.
The employer does not have to pre-pay for coverage, thereby providing for improved cash flow.
The employer is not subject to state health insurance premium taxes.
The employer will take advantage of Evrostia's pre-agreed rates and "closed hospitals' premiums".