Health plan administrators are hungry for innovation — especially in provider access and contracting, member steerage, and member experience — according to a recent survey conducted by Goodbill.
The June survey polled 20 professionals representing 18 independent third-party administrators (TPAs) across the country. When asked which areas are most in need of innovation, provider access and contracting topped the list, with 55% of respondents pointing to it as a major pain point.
“When moving into a new area, we are always behind in the provider contracting at fair rates,” said John McCormick, CEO of Texas-based benefits firm Ovation Health.
“When moving into a new area, we are always behind in the provider contracting at fair rates,” said John McCormick, CEO of Ovation Health.
Coming in next were member steerage (40%) and member experience (35%). Both reflect a growing need for smarter tools that help members make better care decisions before costs are incurred.
Todd Archer, President of Oklahoma-based Concierge Third Party Administrator, said he sees a relatively untapped opportunity to better leverage pricing data to drive improved outcomes.
“Finding ways to utilize price discovery and transparency to improve members’ outcomes and experience” is where innovation is most needed, Archer said.
Record retrievals ranked fourth, cited by 25% of respondents. It's a manual, time-intensive process that continues to strain plan administrators.
“Provider offices are short-staffed, and collecting the necessary documents to adjudicate a claim can be time-consuming,” said Richard Hardin, CEO of Oklahoma-based Edison Health Solutions.
“Collecting the necessary documents to adjudicate a claim can be time-consuming,” said Richard Hardin, CEO of Edison Health Solutions.
When it comes to cost, there’s one clear frontrunner: specialty drugs. Over half (55%) of survey respondents cited them as the top cost pressure facing their clients today.
“Our biggest pain point is J-codes,” said Daniel Demyan, cost containment strategist at Roundstone Insurance, which operates its own in-house TPA, Bywater. “But we also have to deal with high-cost non-emergent procedures and radiology claims.”
"Our biggest pain point is J-codes,” said Daniel Demyan, cost containment strategist at Roundstone.
Hospital claims came in a distant second (15%), followed by stop-loss and plan premiums at 10% each.
Finally, when asked to name the most frustrating part of managing claims, 30% of administrators pointed to managing appeals and denials — a process that lacks standardization, is often labor-intensive, and frequently creates friction with providers.
Claims repricing came next (20%), followed by lack of price transparency (15%).
The remaining votes were scattered across multiple areas, including: record retrievals, claim routing across multiple vendors, Independent Dispute Resolution (IDR) disputes, manual support for custom plans, and hospital bill negotiations.
We’re always looking to highlight the real challenges (and bright ideas) from health plan administrators and benefits advisors on the front lines. Let us know at partner@goodbill.com.
The latest news from Goodbill, including partnerships, product launches, and awards.
.jpg)
Employers are asking tougher questions, benefits advisors say.
Clearwater members now get access to Goodbill’s full suite of hospital savings services.
The third-party administrator for self- and level-funded plans now offers Goodbill to clients.
