Now that a new TPA has been selected, what does that mean for you and your carrier on the topic of claims data? While it may sound easy to “move data” from one entity to the next, there are numerous considerations pertaining to data continuity and quality. Below are some common topics to consider during the typical 3-6 month transition time.
To satisfy both insured and insurer requirements the TPA must capture numerous fields of claim data for each line of insurance. For example, Workers’ Compensation claims often consists of 180 fields of data. As you would expect, often there is a difference between data formats between TPAs format.
Implications to the Insured
- RMIS System Mapping: If your RMIS system is currently receiving a data feed from the outgoing TPA, there will be considerations in the conversion timeline for data mapping, test runs, and IT manpower availability. Additionally, many insureds take this opportunity to revise location coding or other key risk indicators to better meet their evolving RMIS needs, which may also impact the timeline.
Implications to the Carrier
- Data mapping from the outgoing TPA’s claim system to the Incoming TPA’s claim system: Mapping has to occur between the previous TPA, the carrier, and the incoming TPA. As a rule of thumb, the insurer and incoming TPA will request at least three sets of test data to confirm data quality and stability. All data from the previous TPA is expected to be included and translated to the incoming TPA claim system. The transition team will perform several quality checks that specifically analyze data continuity and completeness.
- Data Continuity: The analysis focuses on various data items including, but not limited to, policy number assignment, financial values, location coding, coverage verification, state assignment, and all NCCI data fields required for carrier regulatory compliance. The data analysis will also recognize and make allowances for the uniqueness of each TPA’s claim systems and incorporate those considerations when processing the converted data through the carrier’s systems. The intention is to minimize any interruptions in meeting financial and regulatory claim reporting responsibilities.
- Data Completeness: The data analysis will also ensure that all claims that were previously reported have been converted and are included in the carrier TPA data feed. Any changes in the claim count or values are reviewed for validity.
The transition process typically takes 3-6 months to complete and will include representatives from the incoming TPA conversion team, the insured, the carrier conversion team, as well as the broker. The project manager at the incoming TPA will maintain the implementation project plan with all tasks, deadlines, and responsible parties defined. We have found pre-scheduled weekly conference calls involving all stakeholders can help insure that the implementation is complete and successful.
At the end of the day, transitioning can be smooth if expectations are set realistically and all parties are committed. Just be ready to put in the work!
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