About Players and Roles in SIHP
- Third Party Administrator (TPA) – Third Party Administrators handle all the administration surrounding claim payments for the self insured client. The client will fund all claims for payment through the TPA. All claim reporting, data requests, monthly billing and eligibility changes are handled through this corporate institution. The TPA will also coordinate with Stop Loss carriers and Provider Network access to ensure a seamless plan that encompasses all players involved in SIHPs. Fixed costs associated with TPAs are paid monthly on a per contract basis (Single, EE/SP, EE/CH, Family, etc)
- Stop-Loss Carrier – A Stop Loss insurance carrier provides risk protection against large individual claims as well as against total claims paid on a 12 month annual basis. This player acts as your primary insurance source for a SIHP. Fixed costs for stop loss coverage are presented in monthly premium format based on contract (Single, EE/SP, EE/CH, Family, etc.)
- Provider networks – Provider Networks offer discounted fees for medical services should a participant receive treatment at a contracted facility or physician. Provider network fees are built into the fixed costs associated with SIHPs and are paid monthly on a per contract basis with one contract (Single, EE/SP, EE/CH, Family, etc.)
- Case manager – Case managers coordinate care for high risk participants on SIHPs in order to ensure the health risks associated with such individuals are being treated properly and cost efficiently. Case Managers may be assigned to any one person when such medical issues as obesity, diabetes, heart issues, cancer treatments and organ transplant recipients are prevalent with any individual on the plan. Case Management fees are a fixed cost presented monthly per contract.
- Broker/consultant – Brokers and Consultants act as a liaison between administrators of SIHPs and their respective employer groups. In many cases, brokers/consultants will play the role of human resource managers when it comes to the benefit side of managing such programs. With the right background, a broker/consultant can be an invaluable resource when it comes to managing SIHPs.