Patient Services Solutions

You likely know the name of your private insurance carrier and you may even know the name of your employer's worker's compensation insurance carrier--but what you may not know is that these insurance carriers have little to do with your actual claims.  Instead of doing the back-office work themselves, they contract with Third Party Administrators, or TPAs.  TPAs are responsible for a wide number of tasks. They may conduct Utilization Reviews for medication and medical procedures and issues authorizations or denials. They may handle pharmacy benefits, or contract directly with the pharmacy benefit managers (PBMS) that process the pharmacy claims. They handle all billing for medical providers, and pay those providers based on contractual agreements. The TPA may have complete control over every financial aspect of your private insurance or worker's compensation claim. Sedgwick or United Healthcare may be your insurance carrier in name only.  Insurance carriers contract with TP

If you are dealing with a work-related injury, an ongoing health issue, or simply your family's standard medical needs, you probably receive a lot of paperwork. Some of it isn't easy to understand, and sometimes it's not clear if what you received is a bill for services.  Explanation of Benefits (EOB) are statements from the insurance carrier regarding every item billed by a provider. For example, you may go see your primary care physician for an infected finger, but while you're there you may also discuss your current medications, and have your sinuses checked for polyps. Each separate procedure will be submitted to the insurance carrier with a medical billing code, and the insurance carrier decides based on those codes what and how much to pay.   Those are the codes that will appear on your Explanation of Benefits. At the bottom of the statement, normally in small print, there will be a legend defining each code. Sometimes those codes are easy to understand--maybe one

Pharmacy Benefit Manager (PBM ): Third party companies such as OptumRX, ExpressScripts, and CVS Scripts that contract with insurance carriers and coordinate with pharmacies to process pharmacy benefit claims.  The Big Three process over 70% of pharmacy insurance claims in the United States and they they are not obligated to ensuring patient care or maintaining the standard of care. They promise to reduce costs to insurance carriers and profit from minimizing care to patients. Third Party Administrators (TPA) : Third party companies that are contracted with insurance carriers to administer claims, including adjust and adjudicate, guarantee payment, utilization reviews of medical and pharmacy authorizations, contract with providers, and accept or deny liability.  Claims: Payment requests from medical providers or pharmacies submitted to the responsible party.  Responsible Party : The responsible party for a claim is the person or entity legally obligated to provide payment for services