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.
Test “we can integrate with anyone”
Integration is not the same as mapping. Vendors send inconsistent files, and some lack the technology, the team, or the business case to connect at your plan’s size. Ask what the TPA requires of a vendor, whether it charges a fee to connect to one it has not worked with, and whether it has a preferred vendor list and what happens if you deviate from it.
A pattern worth catching early in the sales cycle: “everything flows into our portal” later becomes “we are not integrated with that vendor, but you can use ours.” That is a mis-sold implementation. Ask for specifics on each of your vendors before the contract, not after.
Prior authorizations on claims
A prior authorization only protects members if it reaches the claim. Ask:
- Is the authorization requirement set at the benefit level or the procedure code level?
- Do flagged claims pend until the authorization is found?
- Does the authorization attach automatically from the medical management vendor’s feed?
- If it does not attach, are examiners told to look for it, or is a penalty applied automatically? If a penalty is applied and an authorization exists, how does it get corrected, and who notices?
Members should never be the safety net.
Who owns the vendor integrations?
Ask who owns them, who runs them, and who reports back to you and your broker. Some TPAs are becoming more hands-off, leaving the broker to manage the project. If that is the answer, it is work your side will carry. Ask about:
- Communication. Will the broker be copied on every integration email? Open threads and unresponsive vendors are visible that way, and no one learns three weeks later that the project is behind.
- Tracking. What is the status cadence, and what detail does the implementation portal actually show?
- Testing. What are the timelines, and do test and audit results go to all parties with a clear “configured, tested, live” confirmation?
- After go-live. When an eligibility feed breaks because of a plan mapping error or a formatting problem on an ID, does the TPA run point or send it back to the broker?
What to put in the contract
Two items come up repeatedly: a fee reduction if a vendor cannot be integrated, and service levels for integrations that suffer recurring feed or claims problems.
Timing
If your effective date is January 1, integration testing is the first thing squeezed when the calendar gets tight. Ask for the implementation timeline in writing, with the testing phases visible.
Frequently asked questions
How long does a TPA implementation take?
It varies with the number of vendors and plan complexity. Ask for a written timeline that shows build, file testing, and audit as separate phases.
Who is responsible for connecting my PBM and medical management vendor?
It should be defined before you sign. If it is not the TPA, know who it is and whether they have the time and access to do it.
What integration failure comes up often?
Eligibility and plan mapping errors, which can stop a feed or send claims to the wrong plan.