No broker or employer is expected to know every question in this series, or what every answer means. I have written them out so you can use them. Putting them together, knowing which threads to pull and what one answer means next to another, is the work I do with plans and brokers in Under the RFP.
Start with the A-to-Z walkthrough
Ask: “Walk me through your claims lifecycle, from the moment a claim arrives to the moment it is paid.” The first answer will be high level, something like claims come in, get repriced, and get adjudicated. That is fine. Its purpose is to show you where the gaps are so you can drill into them.
Then ask about repricing. If an outside repricer or network is involved, ask about average turnaround, how files move (API, EDI, or file transfer), and how turnaround is measured. A number counted from receipt and a number counted from the repricer’s return are different numbers, and so are business days and calendar days. A well-run, scheduled file process can still turn claims quickly. The question is what your members and providers will actually experience.
Where tiered plans get hurt
In a tiered design, a narrow steered network sits at the top, a wrap network sits in the middle, and reference-based pricing covers the rest. Plans are underwritten on the assumption that members will use the top tier at its lower repricing level. Three situations test whether the TPA’s process holds up:
- Provider overlap. The same hospital can appear on more than one roster at different rates. Ask open questions: “When the same provider is on more than one contract, how does your system know which tier a claim belongs to? Is that identified every time or caught manually?”
- Wrong submission path. Providers sometimes send claims through an outdated or incorrect route. Ask what happens when that occurs and how a corrected claim is handled.
- Fixing the benefit but not the price. When a claim is moved to the right tier, ask exactly what changes on the claim. Restoring the member’s benefit level without correcting the repriced amount creates a mismatch with the plan document and with what the stop-loss carrier underwrote.
Other scenarios worth testing
- No Surprises Act. “We take it into consideration” is not an answer. Ask how the system enforces it, and what happens when an emergency room visit turns into an inpatient admission.
- Hospital-based providers. Anesthesia, pathology, and radiology often bill separately from the facility. How does the plan treat them, and how does customer service explain it to a member who went to a top-tier hospital?
- Referrals to a higher tier. When the network does not offer a service, a referral may move a claim up a tier. How are referrals captured and applied, and how is that tested?
What the answers mean
A manual process can be legitimate if you learn the accuracy rate, the turnaround, and how many people do the work. An automated process can hide errors if nobody reviews what it produces. Whichever you hear, ask whether the answer speaks to repricing as well as benefits.
Frequently asked questions
What is a tiered network plan?
A plan that pays different benefit levels and uses different repricing depending on the provider’s tier, usually to steer members to lower-cost providers.
Why does provider overlap matter?
When one provider sits in two tiers, standard matching methods may not tell the TPA which one applies.
Who at the TPA should explain claims routing and tiering?
Someone who works claims operations or plan build, not only the sales lead.