In the work comp managed care/claims world, some vendors’ revenue maximization efforts are getting ever more clever. I know, I know, I’ve posted on this several/numerous/multiple times before, but to my never-ending amazement, these practices continue. So here are the top ten warning signs to watch out for (sorry for ending with a preposition…)
Before you start, realize that all TPAs are not out to rip you off, all managed care vendors are certainly not either, and the soft market and unreasonable demands by employers have forced many claims administrators to look for revenue wherever they can get it.
That’s fine, as long as you know where your dollars are going…
10. your TPA won’t let you use your own managed care vendors.
9. your TPA won’t offer a bundled price, including all managed care services. Even worse if you never asked for one.
8. savings reports focus on reductions below charges and don’t show reductions below fee schedule/UCR.
7. the TPA determines which cases ‘need’ case management – and your case management fees continue to grow. sometimes this appears to be OK, as the cost per hour is a deal, but it’s highly likely the hours worked are ever-increasing.
6. the TPA won’t sign any statement like this one. Unfortunately, that doesn’t mean the TPA isn’t lying, as some may sign the statement anyway knowing it isn’t true.
5. the TPA won’t provide copies of any contracts with managed care vendors.
4. the TPA agrees to provide a great deal on claims admin services, with the fine print noting that they have complete control over managed care, investigative, legal, and other claims support services.
3. the TPA’s claims admin price is way, way better than the competition’s. There is no free lunch, and if the deal is too good to be true, rest assured you’re getting ripped off.
2. the claims staff you meet during the pre-implementation meetings disappears when claims come in, replaced by inexperienced/non-experienced/completely ignorant ‘staff’
1. you are paying for bill review on a percentage-of-savings-below-charges basis, which motivates the vendor to find the highest-billing, highest-utilizing providers and let them run roughshod over your bank account, all the while trumpeting the ‘savings’
I’m sure there are more; feel free to contribute your own.
What does this mean for you?
Kinda obvious, don’t you think?
Dec
7
