This client had a previous TPA for several years and approached IPA Solutions looking for responsive service, enhanced capabilities, and a competitive rate for performing their claims management services. The client has a shareholder pool distribution using a historical average methodology, and additional sub fund pool distributions for coordination of benefit claims, sub-contractors, and medical supplies.

IPA Solutions was able to exceed this client’s service expectations by providing the service transfer with no interruption, expediting the adjudication cycle and developing sophisticated management reports for use in utilization review and quality assurance. IPA Solutions did all this while cutting the client’s claims management expenses by over $65,000 per year.

The specialist physicians who practice at this hospital complained that they were having financial difficulties in continuing to provide uncompensated care. The hospital decided that in an effort to help the physicians they would pay the claim of the uninsured patient if the patient failed to make payment. The hospital was initially using an internal clerk to pay the specialist claims at the local Medicare rate, but the hospital was finding that as the volume grew they not only had an operational problem but a growing financial burden as well.

IPA Solutions stepped in and took over this process and implemented the following changes: (1) setting up a budgetary pool of monies to be used in paying these claims, (2) actually adjudicating the claims applying edits against inappropriate billing, and (3) trying to recoup the expended money from the patient or any coverage that may be available to the patient.  These steps saved the hospital money, allowed the hospital to plan and budget for the expenditure, and freed the hospital from the operational burden of paying claims so that they could focus on their core business of providing care to the community.