How ASOs & TPAs are helping HealthCare Payers & Self-Funded Plans (P1)?

How ASOs & TPAs are helping HealthCare Payers & Self-Funded Plans (P1)?

ASO (Administrative Services Organization) is a term used in the healthcare industry and refers to a third-party organization (TPA) that provides administrative services to health insurance companies or self-funded insurance plans. TPA (Third-Party Administrator) is another term used in the healthcare industry, and it also refers to an organization that provides administrative services to health insurance companies or self-funded insurance plans. Both ASOs and TPAs help health insurance companies or self-funded insurance plans manage their administrative tasks more efficiently and cost-effectively. They bring to bear various technologies and workflows to streamline claims administration, manage provider networks, and improve customer service, among other things. Self-funded plans may use ASOs or TPAs to administer their plans, but the employer or plan sponsor ultimately bears the financial risk. It is difficult to estimate how many lives are covered under self-funded plans in America without access to specific data. However, according to a 2020 survey by the Kaiser Family Foundation, about 60% of U.S. workers with employer-sponsored health insurance are enrolled in self-funded plans. In 2019, the Employee Benefits Research Institute (EBRI) estimated that about 100 million Americans were covered by self-insured health plans. However, it's important to note that not all self-funded plans use ASOs or TPAs to administer their plans, and some may manage their plans in-house. Workflows of ASOs & TPAs and the technology used to deliver these workflows:

Claims Administration: One of the primary workflows of ASOs and TPAs is claims administration, which involves processing and adjudicating claims submitted by healthcare providers (P2). To accomplish this, ASOs and TPAs leverage various technologies, such as claims processing software that automates the processing of claims, reducing the need for manual intervention. Additionally, these organizations use analytics tools to detect fraudulent or erroneous claims and ensure compliance with regulations. Furthermore, the claims administration process may be supported by a customer service portal that allows members to submit claims and track their status. Leading Claims processing software (P4) are United Optum, HealthEdge, TriZetto Cognizant FACETS & QNXT, Change Healthcare, Plexis Health etc.

Benefits Administration: Another important workflow of ASOs and TPAs is benefits administration, which involves managing the benefits offered by healthcare plans. This workflow may include designing and configuring plan benefits, tracking member eligibility and enrollment, and managing member reimbursements. ASOs and TPAs use benefits administration software to manage these tasks, including tools for plan design and configuration, eligibility and enrollment tracking, and reimbursement management. Leading Benefits administration software firms include but not limited to: ADP, Workday, SAP SuccessFactors, Benefitfocus, BambooHR etc.

Provider Network Management: ASOs and TPAs are also responsible for managing the provider network, which includes contracting with providers, credentialing providers, and ensuring that members have access to high-quality providers. To accomplish this, ASOs and TPAs use provider network management software that allows them to manage provider contracts, track provider performance, and monitor network adequacy. Additionally, these organizations use credentialing software to verify the qualifications of providers and ensure compliance with regulatory requirements. Leading Provider network management software includes but not limited to HCentive, Veeva Systems, Lumedic, NovuHealth, Jopari Solutions etc.

Customer Service: ASOs and TPAs must also provide high-quality customer service to members, providers, and other stakeholders. This workflow includes responding to member inquiries, managing provider inquiries, and resolving issues related to claims or benefits. To provide effective customer service, ASOs and TPAs use customer service portals that allow members and providers to submit inquiries and track their status. Additionally, these organizations use customer service software that automates the routing and tracking of inquiries, ensuring that they are resolved in a timely and accurate manner. Leading Customer service Platforms (P4) includes but not limited to Salesforce, Zendesk, Freshdesk, Zoho Desk, HubSpot Service Hub, LiveAgent, Genesys Cloud etc.

Other Platform Software (P4) that ASOs and TPAs use to deliver services for Payers & Self-Funded Plans (P1)

• Eligibility and Enrollment: ADP, Zenefits, Namely, Gusto, Paychex
• Reimbursement management: Conduent, Alight, Infinisource, WageWorks, HealthEquity
• Provider network management software: HCentive, Veeva, Lumedic, NovuHealth, Jopari
• Credentialing software: MD-Staff, Symplr, Verisys, IntelliSoft, Cactus Provider Management
• Analytics tools: IBM Watson Health, Tableau, SAS, SAP, Oracle

Overall, ASOs and TPAs leverage a variety of technologies to deliver their workflows, including claims processing software, benefits administration software, provider network management software, credentialing software, and customer service software. These technologies allow these organizations to manage their administrative tasks more efficiently and effectively, ensuring that members receive high-quality healthcare services.

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