When selecting a stop-loss provider, it is essential to ensure that the TPA (Third Party Administrator), plan, and stop-loss carrier are aligned in their approach to cost containment. The primary purpose of purchasing stop-loss insurance is to protect the plan from the financial impact of high-cost claims. While no one anticipates filing a catastrophic claim, it is crucial that claims are handled appropriately when they do occur.
If the TPA and stop-loss provider are not working in tandem as a cohesive cost containment team, the plan may face challenges in receiving the expected reimbursement. This outcome is undesirable for all parties, including the TPA and stop-loss carrier.
At USBenefits, we view our role as a proactive partner in ensuring that the plan is reimbursed fairly and in accordance with both the plan document and stop-loss policy. To achieve this, we engage with new TPAs as soon as a new customer is onboarded with USBenefits. This collaboration begins with sending our welcome package to the TPA, which includes all the necessary forms required to file specific and aggregate claims with USBenefits. Additionally, we provide a list of claim types that may require additional review by both the TPA and USBenefits.
We also encourage the TPA to submit high-dollar claims exceeding the specific deductible for advance funding review. This enables USBenefits to review the claim before payment is made to the provider. If, after our review, we determine that there is no opportunity for cost savings, we will proceed with reimbursement. Conversely, if we identify potential cost-saving opportunities, we notify the TPA and discuss whether there are any reasons—such as network considerations—that would prevent further review of the claim.
Once we receive confirmation from the TPA that additional review is warranted, we forward the claim to one of our approved vendors for further evaluation. Our vendors support their findings by referencing relevant medical protocols and the plan document.
Following the vendor’s review, we provide a detailed report to the TPA for their review and approval. If the TPA concurs with the vendor’s findings, we ask them to proceed with payment based on the review and forward the detailed report to the provider. This level of transparency ensures that the provider understands the rationale behind the payment, which allows them to appeal the decision if they choose to do so.
By taking this collaborative and transparent approach, USBenefits helps ensure that cost containment efforts are managed effectively and in the best interest of the plan, while fostering strong, cooperative relationships with our TPA partners.
