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So Your RFP Results in a TPA Change, Now What?. • Jo Ann Wood Manager, Claims Consulting Solutions Bickmore Arizona State University education and experience with clients changing TPAs enables Jo Ann to provide helpful tips for meeting needs of your stakeholders. • Paula Maguire - PowerPoint PPT Presentation
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So Your RFP Results in a TPA Change, Now What?
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• Jo Ann WoodManager, Claims Consulting SolutionsBickmoreArizona State University education and experience with clients changing TPAs enables Jo Ann to provide helpful tips for meeting needs of your stakeholders.
• Paula MaguireSenior Vice President - OperationsTRISTAR Insurance GroupBrown University education and experience in operations at TRISTAR, Risk Enterprise Management and GAB Robins equips Paula with practical solutions to share.
• Lauren EibRisk Manager, Department of Finance and Risk ManagementPima County, ArizonaAn MBA in Finance from the Virginia Commonwealth University and long term experience in Risk Management enables Lauren to provide real experience in changing TPAs.
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What to Expect
• Devise a strategy for getting the key attributes optimizing your program's effectiveness adopted by new TPA and your stakeholders.
• Adopt a plan for communication, data mapping and a smooth transition.
• Study the critical elements of a request for proposal (RFP) that attracts a strong TPA.
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First Strategy
Follow the Golden Rule• Be appreciative of the outgoing TPA
Gain Cooperation in Making Transition
Service = Future Reference
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Second Strategy
Build Internal Culture:• Clarify program goals• Maintain regulatory compliance• Carry out plans within authority• Develop dispute resolution process
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Entity-wide Frequency and Severity
Fiscal Period
Employee Full Time
Equivalents#
Claims$
Incurred
$ Avg
Incurred / Claim
$ Avg /
Employee
# Claims /
100 Employees
06/07 4,296 677 12,968,659 19,156 3,019 15.76
07/08 4,334 736 13,521,228 18,371 3,120 16.98
08/09 4,511 764 18,981,094 24,844 4,208 16.94
09/10 4,524 843 12,410,174 14,721 2,743 18.63
10/11 4,525 682 12,865,244 18,864 2,843 15.07
11/12 4,448 667 11,713,991 17,562 2,634 15.00
TOTAL 26,638 4,369 82,460,390 18,874 3,096 16.40
Claims Data provided by Tristar
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Reach Entity-Wide Organization
• Top claim producing departments• Department heads• Claim liaisons• Key peripheral partnerships• Lines of communication
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Focus on Selection StrategyCriteria Criteria description Max. Points Available
a. Experience of the Firm 15
b. Key Personnel 15
c. References 5
d. Project Plan 30
e. Cost 20
f. Sustainability 15
Total Points 100
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Third Strategy Build Relationships
I. Delegate responsibilitiesII. Set performance targets
Performance Consistency Claim resolution targets Expense management targets
III. Consider incentives
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Operations Management
Understand Your Current TPA Arrangement Notice of Termination Potential Windup Costs in Current Contract Carrier Notification and Approval for Claim Transfer Can You/Should You Take the Tail Claims
Announce the Change Internal to Your Teams Outgoing TPA – Account Manager Vendor Partners State Insurance Departments
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Operations Management Bring the Transition Teams Together
Account Managers or Transition Leaders to Coordinate Key Teams
Transition Plan Published and Shared Identify Key Tasks Understand Deliverables by Group Establish and Agree on Due Dates Schedule Follow-up Calls and Updates Through Transition Track Progress and Monitor Delays Delivery Checkpoints – Stay Informed Be Ready for First New Claim at New TPA Stick to Your Plan
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Operations Management
Maintain Cooperation from All Parties Ongoing Claim Handling at Outgoing TPA IT Transition Plan
o Test Files Received Timelyo Data Mapping Progressing on Scheduleo Show-Stoppers Identified and Resolved
Preparation of Tail Claims for Transfero Schedule and Fund Advance Indemnity Payments o Clear Communication to Advance Payment Recipients – Not a
Banking Error in Your Favor Your Claim Handling Instructions Published
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Operations Management
First Day of the Last Time You’ll Change TPAs All Transferred Claims Present and Accounted for at New
TPA New Claims Intake, PBM, UR, Early Intervention, Crisis
Management – Ready to Go Kick Off Meetings Transition Follow-up Meetings Funding in Place Wind-down Complete at Outgoing TPA
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Making it WorkRFP – Six month Process
What Do You Want the TPA to Do?• Think about what is currently working well.• What isn’t working – how can that be changed to
make your WC program better?• What don’t you know?
What will you accept as minimum qualifications?
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Request for Proposal
Sections of the RFP1. Glossary of Terms: What is…
• A Medial Only Claim• A Loss Time or Indemnity Claim• Incident, Near Miss, Exposure, Accident, Claim
2. Introduce entity, department & WC program
3. Scope of Project – 1 to 2 Paragraphs
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Sections of the RFP
4. Outline Responsibilities & Authority
• Risk Management Staff• Injured Workers• Department (Supervisors, etc.)• Attorneys• Occupational Providers• TPA
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Sections of the RFP
5. Regulatory Requirements
6. Stakeholder Flowchart
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FlowchartPima County Worker’s Compensation
Phy
sici
anT
PA
Ris
k M
anag
emen
tD
epar
tmen
tE
mpl
oyee
Incurs work-related illness or
injury
Reports illness or injury to
Supervisor
Supervisor completes
Supervisor’s Report of Illness
Injury and submits to Dept. Rep.
Dept. Rep. completes Form
101 and submits to RM
(3 days)
If illness/injury warrants medical
treatment, employee goes to
Occupational Medical Provider
RM copies, reviews and files 101; Sr. Admin Spec faxes
101 and Supv Report to TPA (24 hrs)
Physician evaluates
employee and completes 102
101 used to begin the claim process
(24 hrs)
Physician sends 102 to ICA and
TPA
Has 101 been received?
TPA contacts RM to locate 101
No
Has 101 been received?
Dept. Rep. contacted by Occ
Med MgrNoYes
YesClaim TYPE determined
Three-point contact
investigation started
(24 hours)
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Scope of Work
7. Functional Requirements - Statements• Claims Management• Medical Management• Information System• Cost Containment• Prescription Plan• Litigation Management• Regulatory Reporting
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Scope of Work8. Project Plan - Transition Plan
9. List of Questions • Based on Functional Requirements & Transition Plan• What can you provide that has not been addressed in the RFP?
10. Schedule to go Live
11. Terms & Conditions: • Data Ownership• Confidentiality & Non-Disclosure
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RFP: Self Assessment Section
• Self Assessment Form to be Completed
• Questions to be Answered
• Pricing Sheet to be Completed
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Insurance for Contract
• Standard Insurance Coverage
• Technology E & O Coverage including Network Security
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Oral Presentations
Most Important part of the Selection process• Clarifying questions regarding the RFP• Meet staff and management• Present your RMIS, Claims Process and other
services• Philosophy – What makes you unique? Why should
we hire you?
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Implementation
• Contract• Timeframes• Banking • Annual Service Agreement – Review &
Update• Communicate, Communicate, Communicate
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Teamwork
1. Risk Management’s Responsibilities• Report injury to TPA within 24 hours of injury• Investigations & Loss Prevention• Identify Recordable Injuries• Modified Duty & Return to Work• Communication with WC team
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Teamwork
2.TPA Responsibilities• Claims Management – 3 point contact• Medical Case Management• Cost Containment• Return to Work/Modified Duty• Communication with WC team
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Discussion PointsRFP Process: What’s Right
• Assists purchaser in prioritizing needs• It is a formalized procurement process and more
flexible than the bidding process• RFP can provide detail on the entity and needs• Oral Presentations allow both parties to
communicate directly• Pricing can be revised at the end• Written proposal becomes part of the contract
documentation
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Discussion PointsRFP: Improvements
• Include a Table of Contents• RFPs are difficult to read & respond to• Mandatory pre-bid conferences• Vendors include sales material in responses -
increases reading time• If not awarded the contract, opportunity to learn
the weaknesses in proposal • How should we negotiate Final Price?
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Questions, Final Comments and Contact Information
• Jo Ann [email protected] 714.426.8509
• Paula Maguire [email protected]
•Lauren [email protected]
