Most self-funded plans utilize the services of a third party administrator (TPA) or an Administrative Services Only (ASO) carrier to act as the medical claim payer for their self-funded plans. The services provided by these organizations typically include claims adjudication and benefit plan administration. The services should also include management of service providers to help lower the cost of claims.
The vendors that should be included in self-funded plans include:
- Transplant Networks
- Pharmacy Benefit Manager, including specialty drugs
- Dialysis Management
- Congestive Heart Disease Management
- IV Therapy
- Utilization Review and Case Management
- Bill Audit / Repricing / Out of Network Claim Negotiation
- Durable Medical Equipment
Often times the ASO carrier has contracts with all these vendors and their fees include the costs for all of these services. With a TPA, these services do not always come as a package, and the self-funded plan must pick which vendors and programs to add. Stop Loss carriers will also provide some of these services for large claims on an as-needed basis.
Please review your plans to be sure the managed care vendor services are being provided. Stop Loss Insurance Brokers can review your plans if you are unsure of what services are being provided.