How to Identify An Expert Plan Administrator. Presented by: Penny Barron Client Development Executive, POMCO Group

Transcription

1 How to Identify An Expert Plan Administrator Presented by: Penny Barron Client Development Executive, POMCO Group

2 Agenda POMCO Quick Facts Self-Funding: A Financial Strategy TPA vs. ASO Elements of a Successful Partnership; Key Questions to Ask; Red Flags: 2 Customization Cost-Containment Custom Reporting and Analysis High-Touch Service Model Integrated Service Solutions Compliance Expertise Provider Network Expertise Stop Loss Reinsurance Administration

3 Today s Presenters Jessica Marabella Marketing POMCO Group Penny Barron Client Development Executive POMCO Group 3

4 Established in 1978 POMCO Quick Facts Top 5% of professional administrators nationally Managing nearly $2 billion in premium equivalents Over 550,000+ members nationally Over 650 employees 4

5 Plan Administration Evaluation Options Health benefit plan administration transition options Fully-insured with an insurance carrier, transitioning to self-funding Self-funded with an administrative services only (ASO) agreement with an insurance carrier, considering a transition to a third party administrator (TPA) Self-funded with a TPA, considering a transition to a different TPA 5

6 Reasons for Transition Fully-insured with an insurance carrier, transitioning to self-funding Annual premium increases are unsustainable No access to plan or member-level data to drive plan decisions Need plan customization options and flexibility Dissatisfied with client and member-level service Affordable Care Act (ACA) fees impacting fullyinsured plans 6

7 Reasons for Transition Self-funded with an ASO agreement with an insurance carrier, considering a transition to a TPA Plan options are too restrictive need additional customization Limited access to plan or member-level data to drive plan decisions Provider network customization is limited Dissatisfied with client and member-level services TPAs do not require a letter of credit or bond 7

8 Reasons for Transition Self-funded with a TPA, considering a transition to a different TPA Case management services are outsourced No cost-reduction strategies employed to manage claim costs Customized network solutions do not meet the needs of our members Dissatisfied with client and member services Services and associated reporting can not be integrated Administrative service fees and all additional costs exceed budget allowance Current TPA does not offer suitable ACA assistance and ongoing compliance support and resources 8

9 Fully-Insured vs. Self-Funding Fully-Insured Any budget reserves retained by the carrier as profit Plan designs are pre-determined Networks are pre-defined and cannot be revised to fit access needs ACA tax passed on to employer plans via premium rate increases Self-Funding Conservative budget projections coupled with cost containment strategies resulted in budget reserves Flexibility in plan design customization based on collectively bargained agreements and/or organizational goals Custom provider networks, recruitment, and negotiations Not subject to all ACA fees such as: Health Insurance Tax, state tax, state mandates, or section 332 tax, etc. 9

10 ASO vs. TPA Both can administer a self-funded benefit plan but there are key differences: Administrative Services Only (ASO) Owned by an insurance a carrier as a subsidiary or separate operating division Plan offerings are often limited to the carrier s pre-defined plan options Providers are reimbursement at network rates contracted by their parent organization Third Party Administrator (TPA) Typically independently owned Fully-customizable plans TPAs can offer more innovative reimbursement structures which lends greater discount opportunities and savings to the plan 10

11 TPA vs. TPA Not all TPAs offer the same services and administrative functionality: TPA Offering Basic Administrative Services Network access is leased for an additional fee Customer services and claims processing is outsourced No internal legal or compliance resources Additional services are charged separately (mailings, documentation, network access, etc. Outsourced case management services Expert Benefit Administration Partner Proprietary regional and national network access with customizable tier options Customer service and claims processing occurs on-site by full-trained employees Internal compliance department to advise on federal and state mandates, ACA regulations, and produce plan documents Administrative elements included in bundled rate On-site case managers work to mitigate large claim costs and improve member health 11

12 12 Essential Elements of a Strategic Partnership with an Expert Plan Administrator

13 Benefit design capabilities (i.e.: HDHP and CDHP customization) Unique accommodations for collectively bargained agreements Customization Provider networks Reporting Member communications Tools and resources 13

14 Questions to ask: Is your claims processing system fully customizable? Can you mirror my existing plan design exactly? Can you build a custom network with multiple tiers? Do you have internal compliance experts to advise if my unique benefits are in compliance with ACA requirements, state and federal regulations? Can you administer and report benefit differentials based on employee class (e.g.: union vs. non-union) 14

15 Red Flags ASOs whose customization is limited to variations of predefined carrier plans Strict networks with no custom tier options Reporting limitations Client and member-level tools do not meet the needs of the plan and can not be customized 15

16 Cost-Containment Network discounts should never be the only evaluated factor when selecting an administrator A plan administration partner should have proven processes for mitigating plan payments pre-and post-claim adjudication: Audit review processes Pre- and post-claim custom negotiations Case management services Subrogation and workers compensation coordination 16

17 Questions to ask: Describe the processes you have in place to reduce claim costs? Do you review for billing errors? What are your coordination of benefits (COB) verification processes? Do you review claims for medical necessity? What procedures do you have identify potential fraud and abuse? Do you offer eligibility audit services? Are your case management services administered in-house? 17

18 Red Flags Claims paid based on pre-negotiated rates only Inability to provide internal or SSAE-16 audit results and/or refusal to allow on-site internal audits Financial accuracy rating less than 99% Outsourced medical management services No fraud/abuse protections 18

19 Custom Reporting & Analysis Self-funded plans have access to data to measure and manage their plan strategy Predictive modeling capabilities for financial planning Advanced on-demand client and broker/consultant reporting technology Integration of data for all administered plans (medical, dental, vision, prescription drug, stop loss, disease management and wellness programs, etc.) 19

20 May I see samples of your custom reporting capabilities? Questions to ask: What on-demand reporting tools will I have access to? How frequently will we meet to review the performance of my plan? Will my broker/consultant have access to plan performance data so that we can all collaborate on plan strategy? 20

21 Red Flags Inability to provide plan-specific experience reports Sample reports that do not provide actionable data such as: Cost-avoidance reports Gaps in care Medical treatment compliance analysis Top diagnoses Preventive/routine analysis utilization High claimant data Top providers Performance compared to industry and regional benchmarks 21

22 High-Touch Service Model Four-pronged service model: Client Member Broker/consultant Provider Responsive client service team Specialized, highly-trained member service representatives Commitment to quarterly meetings and additional meetings as needed upon request 22 Access to on-site member resources if desired

23 Questions to ask: Will my benefits team have access to individuals for all of our questions and requests? What online and mobile tools will be available to me, my broker/consultant, and my members to obtain answers to plan, claim, or eligibility questions? Describe your member service training process? Where is your member service call center located? Will members have access to an individual service number? Will you provide call center performance data and analytics? 23 Is your service model predicated upon first call resolution goals?

24 Red Flags Inability to provide member and client satisfaction survey results Inability to provide book-of-business performance guarantee metrics Outsourced member service representatives or a call center located outside of the immediate region or country Client service representative is often unavailable and does not respond to inquires timely 24

25 Integrated Service Solutions Integrated service solutions and plan components (medical, dental, prescription drug, vision, consumer-driven health plans, wellness programs, disease management solutions, etc.) Reporting Administrative capabilities for ancillary services (COBRA, premium billing, CDHP, etc.) Pharmacy Benefit Management (PBM) services 25

26 Will you offer back-office support for my human resource team? Questions to ask: Will you collaborate with my broker/consultant? Will my reporting be integrated? Will my members receive one identification card for both our medical and pharmacy benefit plan? Do you have an online member portal that captures all lines of service? 26

27 Red Flags Inability to offer integrated reporting Inability to partner with existing vendors or partners (pharmacy benefit managers, brokers/consultants, insured ancillary lines, etc.) Individual service teams for each plan type or service solution Limited PBM integration capabilities 27

28 Compliance Expertise Internal legal and compliance resources Global compliance expertise (i.e.: ACA, HIPAA, ERISA) Development of plan documents and amendments Continual compliance resources (blogs, alerts, presentations and client leave-behinds) 28

29 Questions to ask: Do you have staff attorneys and legal experts that will be available to us? Will you be able to assist with annual notice requirements? Will you produce my master plan document (MPD), summary plan document (SPD), plan amendments, and summary of benefits and coverage documents (SBC)? 29

30 Red Flags Lack of internal compliance resources Client service representatives not knowledgeable about federal and state regulations Extra fees to produce plan documentation 30

31 Provider Network Expertise Proprietary network National and regional access Customizable network tier Additional regional leased network options Strategic recommendations for network access based on claims and census evaluation Services beyond regional and national network development 31

32 How will you choose the network that is right for my plan and my members? Questions to ask: Do you have an internal network development team? Do you recruit providers to your network? Will my members have access to a regional and a national network? How often do you renegotiate your provider contracts? 32

33 Red Flags Inflexible networks Evaluation of providers utilized within the past year indicates less than 95 percent network match Less than 95 percent average annual provider retention 33

34 Stop Loss Reinsurance Administration Key consideration for self-funded plans with less than 2,000 employees Protection again unanticipated catastrophic claims and high utilization Strategic guidance as to the deductible threshold, protection terms, and contract length that will best suit your needs Integrated into health benefit plan administration and reporting Advanced funding to optimize cash flow 34 Reporting of all applicable claims data to the stop loss carrier without an additional fee

35 Questions to ask: Will my stop loss recoveries be incorporated into my experience reporting? What is your process for providing recoveries? What are my stop loss premium billing options? 35

36 Red Flags Partnering with stop loss carriers who have received anything less than an A-rating No ability to integrate reporting No advanced-funding option 36

37 Questions? Penny Barron x

38 Stay Informed For more updates on the ACA and trends in benefit administration, visit the POMCO Group Health Care Educator Blog: POMCOGroup.com/blog Subscribe to updates via 38