HM Insurance Group hosted our fourth annual TPA Roundtable September 6-8, 2017. This year’s event was attended by experts representing various TPA organizations from across the country, along with HM leaders and staff who engage with our TPA partners. There also were presenters from InterveneRx and Best Doctors, who shared important industry information with the group.
Throughout the course of the conference, several areas arose as growing trends or hot topics in the current market:
Addiction Treatment Facilities
TPAs are seeing an upturn in unlicensed or unqualified facilities marketing themselves for the treatment of addictions. They frequently bill extremely high-cost charges for standard procedures, such as testing, and these charges are passing through without proper scrutiny or pushback. In order to guide patients from the use of these facilities, language should be included in the plan document addressing the accredited facilities that are to be used by covered plan members. Claim reimbursement for the treatment of drug addiction should be contingent on the use of accredited facilities and individuals.
Ineffective Pharmaceuticals
The cost of claims related to ineffective pharmaceuticals also is growing. This issue can be given attention in the language of the underlying plan document by specifically addressing ineffective or inappropriate drugs in PBM contracts, in addition to including language that allows refunds related to ineffective pharmaceuticals.
Domestic Exclusions
Prior to submitting claims for Stop Loss reimbursement, TPAs should apply Domestic Exclusions in the claims data. Neglecting to reduce claims submitted for the amount related to Domestic Exclusions can result in inaccurate submissions, including claims that do not meet the deductible.
The annual TPA Roundtable is a great time to gather feedback and important information, but we’d love to hear from our TPAs year-round. If you have any thoughts, concerns or information you’d like to share, please reach out to Dom Palmieri, senior vice president, Operations and Strategic Partnerships, at domenic.palmieri@hmig.com.