Third party administrator

A third party administrator (TPA) is an organization that processes insurance claims for a separate entity. [cite web|url=http://www.pbs.org/healthcarecrisis/glossary.htm |author=PBS |title=Glossary of Healthcare terms |accessdate=2008-02-26] This can be viewed as "outsourcing" the administration of the claims processing, since the TPA is performing a task traditionally handled by the company providing the insurance. Often, a TPA handles the claims processing for an employer that self-insures its employees. Thus, the employer is acting as an insurance company and underwrites the risk. The risk of loss remains with the employer, and not with the TPA. The employer may also contract with a reinsurer to pay amounts in excess of a certain threshold, in order to share the risk for potential catastrophic claims.

An insurance company may also use a TPA to manage its claims processing, provider networks, utilization review, or membership functions. While some third-party administrators may operate as units of insurance companies, they are often independent.

Health care

Third party administrators are prominent players in the managed care industry and have the expertise and capability to administer all or a portion of the claims process. They are normally contracted by a health insurer or self-insuring companies to administer services, including claims administration, premium collection, enrollment and other administrative activities. A hospital or provider organization desiring to set up its own health plan will often outsource certain responsibilities to a TPA.

For example, an employer may choose to help finance the health care costs of its employees by contracting with a TPA to administer many aspects of a self-funded health care plan.

Commercial general liability

This term is also now commonly used in commercial general liability (CGL) policies or so called "casualty" business. In these instances the liability policies are written with a large (in excess of $50,000) self insured retention (SIR) that operates somewhat like a deductible, but rather than being paid at the end of a claim (when a loss payment is made to a claimant) the money is paid up front by the insured for costs, expenses, attorney fees etc. as the claim moves forward. If there is a settlement or verdict within the SIR then that is also paid by the insured up to the limit of the SIR, before the insurer steps in and pays its portion. The TPA acts like a claims adjuster for the insurance company and sometimes works in conjunction with the inside insurance company claims adjuster or an outside claims investigator as well as the defense counsel. The defense counsel in some situations is selected by the TPA. The point is that the larger the SIR the more responsibility the TPA has over the control of the way the claim is handled and ultimately resolved. Some self insured retentions are in the millions of dollars and the TPAs are large multinational non-insurance entities that handle all the claims. In some cases the insured sets up an entire department within their company (and staffs it with claim savvy people) to act as the TPA as opposed to hiring a commercial TPA company.

External links

* [http://www.pbs.org/healthcarecrisis/glossary.htm Healthcare Crisis Glossary]
* [http://www.michigan.gov/cis/0,1607,7-154-10555_22535_22904---,00.html Michigan Statutory Definition]

References


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