Handling healthcare and insurance claims can be challenging. Third-party administrators and healthcare payors have numerous processes to manage. They have to confirm patients are covered, verify amounts owed, follow rules, and handle all types of handwritten documents. Handwritten processes take time and can lead to mistakes. That’s why claims software is very beneficial. With the right features, this software makes things easier, faster, and more accurate for TPAs and Payors.
Understanding the Role of TPAs and Payors
Third-party administrators and payors play a big role in health insurance. In simple terms, TPAs manage health plans on behalf of employers or insurance companies, and payors are actually the party that pays for the healthcare services. Many of the day-to-day jobs performed by TPAs and payors are:
Claims adjudication, which includes checking and processing healthcare claims
Compliance with policies and regulations
Cost-containment
Communication with physicians and patients.
Since they deal with so many tasks, claims handling software with the right features can really help them work faster and avoid mistakes.
Core Claim Software Features Supporting TPAs and Payors
Now, let’s look at features that help TPAs and payors daily.
Automated Claims Adjudication
Automated claims adjudication means the software can automatically check and determine whether to pay a claim without requiring a person to confirm the payment. The software uses embedded rules, along with built-in AI, to process claims quickly. This saves time. It also reduces human errors. For example, the software can immediately identify incorrect information or missing documentation. TPAs really benefit from this. It allows them to process more claims in less time, saves money, and keeps their clients satisfied. It also reduces turnaround time, increases accuracy, and makes for a smoother operation.
Integrated Reporting & Analytics Dashboard
Claims handling software often includes reporting tools and dashboards for helping teams view and analyze what is happening with claims, providers, and finances. For example, a dashboard can summarize how many claims were paid, how many were denied, and for what reason. It is a tool to help managers discover problems early and to improve their decision-making. Analytics tools find trends and help project future issues. This type of trend analysis supports more informed planning and helps ensure the organization maintains compliance, akin to having an up-to-date roadmap detailing how processes are tracking.
Real-time Eligibility and Benefit Administration
The software provides the functionality to manage employee benefits, including flexible spending accounts, retirement plans, and health insurance. It facilitates benefit administrators in managing enrollment and eligibility, helping make the process a bit easier for new hires and tracking coverage changes. The software also provides the capability to customize the plans, providing different needs for clients, like eligibility and contributions. It is also used to provide employee self-service features which allow employees to live online options to manage their benefits, for example, taking actions to assist with claims reimbursement, which reduces admin work and allows employees greater means of managing and leveraging coverage.
Provider and Payor Network Management
Claims management software allows administrators to track and manage the providers in their network by keeping a thorough list of the doctors, hospitals, and specialists they use and allowing search capabilities by specialty, location, or network affiliation. The software also supports administrators with negotiable contract negotiations, renewals, and compliance checking by tracking reimbursement amounts and performance metrics. The TPA systems also allow for the tracking of the credentialing process and compliance with credentialing, and keep providers compliant by tracking when licenses expire, reporting provider credentials, and providing fast resolution to regulatory or contractual issues.
Managing healthcare claims and networks is complicated for third-party administrators and payors, and they require resources beyond just staffing; they need technology to help them. Claims software can apply automation, real-time data access, and even advanced analytics to help third-party administrators and payors revolutionize how they conduct daily operations, minimize the potential for errors, and ultimately provide superior customer service.
Don’t let outdated methods stand in the way of progress. Upgrade to an advanced claims handling system and advance your operations today!
