Breaking Down the Self-Funded Data Problem

Here is a very basic summary of what happens when an employer is self-funded. They hire a TPA or carrier to pay their claims. Providers submit their bills from Member visits to the TPA for payment. The TPA then reports to the Employer on amounts paid for claims.

Those of us in the industry know that’s not the whole picture and the process is much more complex. There are more players involved in the reporting game and the TPA is responsible to pass information to the Broker, Reinsurance Carrier, Population Health Vender and others. With current methods of spreadsheet reporting, the sharing of information is never as easy as “Me-to-You and back-to-Me”. Everyone gets a piece of data and is expected to accurately report to all parties. If we’re honest, the process resembles a school PE teacher setting up a dodgeball game by just dumping out a bag of rubber balls and saying “go”. Let’s follow the bouncing ball?

TPAs Have the Data To Report

After payments are made to the Providers, the TPA reports to the Employer the claims amounts. 

Employers Get Pieces of the Data

As the policy holder, the Employer should be most-in-the-know when it comes to the performance and projections of the plan. Without data centralization and full information transparency, the reporting received is far from the full picture.

Lack of Data Transparency with Brokers, Reinsurance Carriers, Population Health Vendors & Others

At this stage we see the complexity of the reporting increase as multiple players require data to complete their responsibilities to the Employer. In this model, the TPA is only providing the minimum data necessary to each vendor and none of the parties have full transparency with the information.

Reporting Madness!

The illustration to the left attempts to show a flow chart of which player is reporting to whom. It looks more like a chaotic cluster of confusion and inefficiency. 

Sample Reporting Pricing

The Solution

By eliminating traditional spreadsheets and bringing all the players to one place for the data, Self Insured Reporting is a giant leap forward in security, accurancy and effciency in reporting for self insured employers.

Our platform also brings in not only claims, but all fixed costs as well.  We collect reinsurance contract details, administrative charges, stop loss reimbursements and more to allow for truly comprehensive reporting.

RECEIVE: Medical Claims + Pharmacy Claims + Membership

RESULT: Transparent Reporting For All From

Reporting not only claims, but all fixed costs to give a true picture of total costs.

Sample Reporting