Don’t Settle for Sub-Par Reporting from Your Healthcare TPA

Posted in: Commercial Insurance, Risk Management Consulting

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Operating an elder care facility or senior living community in today’s convoluted healthcare landscape comes with challenges. On top of caring for patients, there are new laws to learn, claims to submit, records to update, litigation to manage, procedures to implement — and much more that relates to your long-term and day-to-day operations. Staying ahead of these responsibilities can take a toll on your staff and detract from your core focus as a healthcare facility, which explains why many companies need a third-party administrator (TPA) with strong healthcare experience to manage their liability and professional (GL/PL) claims.

What, exactly, does a GL/PL TPA do? In the healthcare industry, TPAs handle all or part of the general and professional liability claims process. They can also serve as litigation managers and play a vital role in lowering your risk.

In my last post, I discussed why a TPA with expertise in litigation management can be an invaluable asset to healthcare facilities because of the high risk of lawsuits filed by residents, families, and at times, employees. Here, I want to share another side of a TPA’s work that feeds into these other areas: the reporting your TPA provides.

You may think of reporting as a mundane service that doesn’t really affect your bottom line, but the opposite is true. The reports your TPA delivers can have a significant financial impact on your facility. What kind of reporting do you want from a TPA? As you search for and vet various TPA options, inquire about these specific aspects of reporting, and choose a partner who can meet these monthly needs.

Ask about timing and frequency.
How often and when your TPA sends reports matters, so find out before you decide to sign on. Standard industry practice is to send client reports once a quarter or just a couple of times a year. But in my experience, that’s not nearly enough. Our team found monthly reporting ensures that our clients are fully aware of the status of their claims at all times. Clients need to know what’s happening with their claims for a number of reasons — to determine the best resolution strategy, budget future expenses, address clinical practices in the facility, and more. Without our monthly reports, clients can’t intervene in the claims process in a timely matter, often to detrimental and costly consequences.

Look for depth.
Most insurance carriers and TPAs provide a quarterly or annual loss run on claims that often only specifies payments and reserves. Reports like these really just show the dollars and, at most, include a short sentence describing what happened. This doesn’t cut it when there’s complex litigation going on because these shallow details only tell part of the story. Make sure your TPA provides more than a surface-level account of what’s happening, so you are aware of the most recent positive and negative changes to the claims to help you manage your clinical practices, budget and reputation.

Inquire about range.
If the TPA you’re considering working with provides you just one general report, keep looking. Solid reporting in the healthcare industry calls for a broad approach that lets clients see the full picture, not bits and pieces.

The types of detailed reports you should expect from a solid TPA partner each month include:

  • List of Open and Closed Claims – This report should list the month and year-to-date total count of new and closed claims as well as note the number of claims in litigation.
  • Open Claims Report – Detailed information about each open claim is important. Your report should include paid and reserved totals, a brief description of the claim and damages, and a brief description of the current status, which should be updated regularly, as events unfold.
  • Medical Records Requests – Here you should see all medical records requests for the past month, information on the requester, the reason for the request, and any issues or concerns with the request. This report should also identify potential claims brewing against the facility.
  • For Record Only Incidents – You also need to know about incidents that have occurred in the past month that are determined not to be claims at the time of the report. Incidents can include significant injuries to residents, all visitor incidents, and auto incidents — all of which may or may not develop into claims at a later date.
  • Financial Summary – This summary should provide an overview of financial information on all general and professional liability policies, such as indemnity and expense payments to date, reserves, along with the total incurred for each policy. If your policy has aggregate limits, the summary needs to provide the amounts remaining on the aggregates.

Factor in convenience.
Time is a valuable commodity, and if you’re like many healthcare facility operators, it’s in short supply. While you want depth and range in the reports you receive from your TPA, you also want your TPA to sift through and extract the critical details so you can focus on other priorities. Good TPA reporting puts what matters front and center, instead of sending you off to wade through and decipher countless pages of information on your own.

Are you getting a summary with every report? You should receive a quick overview of information that warrants your attention, such as new and closed claims, significant developments, and upcoming trials. If you choose to drill down and look closely at the details, you can dive further into the reports and bring them up for discussion.

Day to day, it’s challenging for healthcare administrators to pay attention to what’s going on with each claim — and they shouldn’t have to. An effective TPA keeps your team updated and informed in a timely, convenient manner, and gives you the information you need to be proactive, not reactive.

As you search for the right fit, keep these points about reporting in mind, and choose a TPA who can ease the workload of your team, provide expertise in complicated healthcare and litigation matters, and ultimately help you succeed.

PSA’s Healthcare Risk Solutions Team offers all of these detailed reporting services and can help your team through the healthcare litigation maze. Contact me at to find out more.

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