ASSESSING THIRD PARTY ADMINSTRATORS: FROM RFP TO STEWARDSHIP CLM 207 Monday, April 16, :15 p.m. to 4:30 p.m.

ASSESSING TPA’S Your Speakers Barry Wilson – Director, Risk Management – Express – Central Ohio Chapter Nathan Hughes – Risk and Claim Manager – Safelite Group – Central Ohio Chapter Jeff Branca – VP and Client Executive – Hylant Group - Cincinnati

TODAY’S AGENDA Introductions Reasons to consider a TPA review Current TPA environment Preparation for the process Managing the reviews Decision criteria Stewardship review Questions & dialogue Session evaluation

Consideration for a TPA Review Required due diligence Service enhancements, industry specialists Improve costs and/or services Personnel turnover Inconsistent service model Locale considerations Split claim administration from managed care Claim(s) gone wrong

TPA Review Preparation Needs assessment versus current scenario Initial meetings with TPA’s Formalizing requirements and standards Ascertaining decision makers – buyers & users Weighing the primary criteria & scorecard Two stage process – – Initial RFP response – Determining finalists – And the winner is… Communicating the outcome

Needs Assessment – Who & What Coverage specific Industry specialists Claim & category protocols Medical management Claim account executive Designated contacts File reviews – onsite vs. virtual Regulatory compliance Specific adjuster qualifications Banking requirements Two year vs. life of claim Medicare set-aside support Record retention Resolving disputes Insurance requirements Transition plan

THE INSURERS VIEWPOINT Insurer retains fiduciary responsibility – Credit risk – Bad faith – Regulatory compliance Two party contracts Required interfacing criteria – Massive data – Multiple sources TPA liability & fidelity requirements File audits & quality controls

TRANSISTION PLAN Formalize timelines Delineate responsibilities Handling prior claims Hold initial weekly teleconferences Supervision by TPA supervisor Provide frequent & open feedback Solicit insurer’s perspective

SCORECARD CONSIDERATIONS General – Experience & capabilities – Specific line of coverage mix – Quality controls -Best Practices – Regulatory compliance Staffing – Team selection criteria – Workloads & monitoring – Expertise Economics – Fees & costs – Life of claim vs. contract – Transparency issues Specific Protocols – Initial reporting & set up – Reserving criteria – Settlement authority – Service agreement – Special instructions – Investigations & surveillance – Claim review criteria – Banking & funding – Insurance requirements – Dispute resolution RMIS – Capabilities & compatibilities – Benchmarking tools

DECISION TREE Scorecard review Required deliverables Firm’s reputation Specific account team relationship References Transition plan Ombudsman's access Ease of termination

STEWARDSHIP REVIEW What’s the ideal time? Whose involved? Critical components - – Summarize of activities – Identify trends & opportunities – Comment on communications – Team & individual performance – Discuss instructions & settlement authority – Intangibles

ASESSING TPA PERFORMANCE Questions And dialogue

CLM 207 ASSESSING TPA PERFORMANCE Thank you for participating Please submit your session evaluation