TPA Payment Integrity Solutions: A Compelling Market Advantage for Third Party Administrators

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A Compelling Market Advantage for You


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Slow the rapidly increasing costs and risk in health benefit plans while gaining a competitive advantage over your competition. Realize a guaranteed return on investment (ROI) and other compelling value through the strength of HMS payment integrity solutions.


Finding waste at the source

Errors on medical claims, deliberate fraud, and benefit claims abuse translate into rapidly increasing cost for health benefit plans every year. HMS payment integrity solutions are designed to search out the causes and mitigate unnecessary financial drain where it begins – errors made by clinical providers, improper billing, and ineligible beneficiaries. For third party administrators, the competitive advantage is clear. With HMS as your partner, TPAs can pass on significant waste and cost reductions to provide game-changing benefits to customers. TPAs gain a compelling service advantage – one that even the largest competitors don’t have – by implementing HMS solutions for the plans you service.


Employer-funded plans: Filling the service gap

There is a significant gap in the service large insurance carriers typically provide to employer-funded benefit plans. Though they act as TPAs for these plans, their service doesn’t extend to mitigating waste from improper payments. With no countermeasures in place, the cycle of increased plan costs continues year-over-year. By partnering with HMS, independent TPAs can fill the service gap. By offering waste-mitigation services like HMS payment integrity solutions, TPAs can deliver substantial financial savings to the customer – and be seen as a stand out in the market.

The solutions

HMS solutions are designed to eliminate improper payments both before and after claims are paid, by analyzing and verifying claims, finding errors and verifying dependent eligibility, and detecting patterns of abuse or other improper billing trends. HMS payment integrity solutions include:

  • Claim Edits and Analytics. Using the broadest range of pre- and post-pay edits to review claims for error and potential abuse, Claim Edits and Analytics create claim-level breakdowns of improper billing issues and statistical/anomaly pattern analysis to help spot suspicious trends.
  • Clinical Claim Review. Covering Diagnosis Related Group coding, medical necessity, reimbursement methodology, covered vs. non-covered services, readmissions, level of care and others, HMS Clinical Claim Review helps payers avoid many types of errors.
  • Dependent Eligibility Verification. By uncovering the hidden cost to a plan created by ineligible dependents, Dependent Eligibility Verification can deliver a typical return on investment beyond 400%. HMS handles verifications sensitively to ensure employees understand every step in the process and why a dependent may be ineligible.


Taking it to the customer: customizable, scalable solutions from HMS

Like independent TPAs, HMS is nimble, developing solutions scalable to any sized plan. As a TPA, you can pass the benefits straight through to the employer plans you serve, increasing your value to the customer.

TPAs can choose how to bring HMS solutions to market: 1) Use the strength of the HMS brand as a strong selling point to enhance your portfolio, or 2) or brand the solutions as part of your portfolio, while HMS remains invisible to the end customer.

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