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Step #3: Improve the Focus on Implementation

Other than a system conversion, I can’t think of an effort within the TPA world which is as challenging as the implementation of a new client or implementation of changes for an existing client. There are a litany of causes for this, including:

  • Insufficient timing;

  • Failure to set appropriate client expectations;

  • Poor communication between Plan Sponsor, broker and TPA;

  • Incomplete or delayed data and/or definition of client requirements;

  • Parallel implementation of new vendors requested by the Plan Sponsor or broker;

  • Poor planning for new business leading to inadequate staffing;

  • Selling services which are outside boundaries established by the TPA’s operations;

  • Stop loss disclosure or contract issues; and

  • Transition issues from the prior administrator.

Missing from the list, but I think more important, is the lack of dedicated resources, structure and tools within the TPA that establish appropriate checks and balances. In my second Blog posted on January 28, I discussed using a company-wide quality improvement effort as a company goal. Improving the implementation process is an ideal initiative. Minimum components of the process should include:

  1. Ensure that sales reporting is in place to reflect business “in the pipeline,” with covered headcount, probability of making the sale and notes on any special requirements or unique arrangements. That will allow for planning and prioritization of resources.

  2. Initiate detailed pre-sale due diligence on prospects, including plan review, services, employee communication needs and any unique characteristics. At a minimum, this should include review of the Plan Document(s) and expectations around employee meetings and receipt of data from the Plan Sponsor and prior administrator.

  3. Hire or Appoint an Implementation Manager with an attention to detail and previous project management experience. The Implementation Manager will coordinate the resources from all Departments required to have implementation success. It is very important that the Implementation Manager NOT approach implementation from the perspective of IT, Operations or Account Management. Their role is project management and quality assurance, NOT supplementing resources from those Departments or getting absorbed into their processes.

  4. Implement a New Case Transmittal form designed to initiate production of key documents and frame the implementation schedule. This document is intended to be along the lines of a Memorandum of Understanding, and will be completed by the sales team and signed off by the broker and hopefully the new client. It is not intended to be a legal document and should not be developed as such. Essential information includes the Plan Sponsor name and business address, the effective date, dates for planned employee meetings (if applicable), the broker name and address, the intended stop loss coverage and an attached copy of the proposal accepted.

  5. Develop an Implementation Plan or Task List which allows for expansion or constriction based on the total time allowed for the implementation. There should be two versions, a higher level version noting key dates and key completion times, and a more detailed version showing interim tasks which can be used to hold Departments and team members accountable. Two hints here. First, make sure to include clear expectation of broker and client deliverables on the higher level version. This is the one they will see and inclusion will facilitate discussion around how important their role is. Second, build time into the Plan for testing or quality assurance. This is not revolutionary by any means, but the amount of testing I believe is necessary may be seen as such.

  6. Develop a formal implementation data gathering tool, which can be used to set expectations and gather data before the sale is even complete and forces all critical questions to be answered. At a minimum, the following should be included: contacts (for all types of contact), Tax ID and banking information, current plan design information and desired benefit changes, VIP handling, ongoing employee relations issues around benefits, transition issues (what if?), billing and funding formats and finance department needs, employee communications requirements and nuances, and reporting areas of interest.

  7. Develop standardized tools and samples to accompany the gathering tool so that clear and concise communication with the broker and Plan Sponsor can occur. Examples are: Companion Guides for EDI files; sample Benefit Summaries/Matrices (detailed listing of coverage for finite medical services designed to facilitate discussion on coverage and consistently interpret Plans for plan building); sample monthly bill; sample employee communications (including ID card, welcome materials, EOB); sample funding request; and a sample report package or library of available reports.

  8. Prioritize development of documents that are key to the relationship between the TPA and Plan Sponsor. These are obviously the Service Agreement and Plan Document(s). Set a goal that the Service Agreement is delivered to the broker and Plan Sponsor’s within one week from receipt of the New Care Transmittal and the Plan Document(s) are in their hands within one week of receipt of the previous Plan Documents and details of plan changes. You may have noted that I suggested distribution of these documents to the broker AND Plan Sponsor. I have witnessed too many occasions where an intentional or unintentional broker bottleneck resulted in issues for the TPA.

  9. Move the stop loss final underwriting and contracting process along. This is especially true if the TPA has arranged for the stop loss or is being requested to work with a market that it has not previously worked with. Ultimately, if the stop loss is not contracted, at least initial billing may be compromised. Some suggestions related to stop loss are: 1) Have a complete and updated response to the SIIA/SPBA model TPA questionnaire and procedures and reports used for stop loss reporting and claim submission always ready to provide; 2) Maintain a process for reviewing stop loss reporting and claims submission guidelines against the TPA’s standards and gain agreement on deviation to the TPA standards; and 3) Review the stop loss contract to ensure consistency with the Plan Document and TPA policies and procedures.

  10. Build the Departmental culture and staffing required to fulfill all obligations detailed in the Implementation Plan, including timeliness, disclosure and quality. Nowhere is the old adage “one bad apple can ruin the bunch” more appropriate than in the implementation process. Employee “bad apples” are rare, but “bad apple” tasks that are not completed, misrepresented or completed with less than desired quality are far too prevalent.

  11. Finally, identification of “bad apples” and assessment of readiness across the organization is easily the most important part of the implementation process. The senior management team of the TPA must own and promote a comprehensive testing and readiness assessment, to be completed enough in advance of the effective date that corrections can be made. In many cases, it continues past the effective date. The root cause of all failures must be identified and corrective action taken. Minimum areas for testing include:

  • File Interfaces

  • Receipt and loading of enrollment file from Plan Sponsor or their representative;

  • Linkage of enrolled employees to the reporting account structure and plan selection indicated on the Plan Sponsor file

  • Outbound file(s) and confirmation of loading to any vendors involved (PBM, PPO, Care Manager, Fulfillment, etc.)

  • Web Portal(s)

  • Plan Sponsor and/or broker access to web portal

  • Random Participant ability to self-register for portal use

  • Access to all communications materials expected to be in place

  • Links to various business partners/vendors used by the Plan Sponsor

  • ID Cards

  • Verification that final card is 100% match with card approved by client and vendors

  • Final testing of vendor phone numbers via call

  • Verification of count of ID cards produced and mailed versus records loaded from Plan Sponsor file or other source

  • Claims

  • Test plan build via processing of sample claims representing in-network versus OON, various service types and COB

  • Knowledge assessment of Examiners on team slated to handle Plan Sponsor claims

  • Monitoring of QA/audit results for new client claims for 60 days

  • Verify that workflows and payment arrangements applicable to claims-related fees are complete

  • Verify via random audit that accumulators loaded in advance were done accurately

  • Verify that interface between PBM and TPA for accumulators is ready and values appropriately update

  • Verify that rollover arrangements for FSA and HRA have been completed


  • Verify that individual accounts have been set-up with funding amounts established

  • Verify that overall funding account has been set-up and is ready

  • Test inbound fax and e-mail box made available for participant claims filing

  • Customer/Provider Service

  • Verify via calls that phone lines and phone tree/queues have been programmed as expected

  • Verify that on-line documentation to be used for new client calls is accessible

  • Knowledge assessment of CSRs to validate new client orientation has been successful

  • Sample inbound calls to test CSR readiness and accuracy

  • Sample outbound calls to care management partner and PBM to ensure their readiness and awareness of the new client relationship.

  • Care Management

  • Verify that transition plans from the prior care manager have been completed including existing precertification records and case management details, including direct contracted arrangements

  • Verify accuracy of care management partner records of services requiring precertification via test calls

  • Funding and Billing

  • Verify that all accounts have been set up and checked and EOB production is ready

  • If applicable, verify that initial funding requirement is in place

  • Verify positive pay file readiness and acceptability with the bank

  • Audit initial bill based on headcount used in proposal and enrollment records loaded, as well as financial arrangements dictated by the New Case Transmittal and Service Agreements

  • Validate on funding requests and bills that account structure required by the client is reflected on the bills (i.e., locations and other breakdowns)

  • Validate that any “splits” in fees and premiums applicable to “mark-ups” on vendor fees, commissions, etc. have been set-up for post payment reporting and payment instructions complete (W-9, EFT, etc.)

  • COBRA Administration

  • Validate that prior COBRA records have been received from prior administrator and loaded in recordkeeping system. This includes participants within 60 day period following qualifying event, those in the 45 days between enrollment and payment of premiums and those who have enrolled and are covered through their paid-through date. This includes ACH payment arrangements being in place

  • Verify that monthly bills for existing COBRA beneficiaries have been created and mailed

  • Client Reporting

  • Validate that all requested reports for client are produced at month end

  • Review reports for unusual data elements or information which is significantly different than what is known for the client (covered headcount, number of claims processed, claim amounts funded)

  • Validate that produced reports include account structure and reporting groupings specified by client

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