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Health Care Case Study

Case #12005: Medicare Advantage Third Party Administrator (TPA )

The Senior Services division of a national Health Benefits Organization had recently expanded their Medicare Advantage (MA) Private Fee for Service (PFFS) product. Questas was engaged to assist the Claims and Customer Service areas of this division in seamlessly transitioning these functions from an under-performing third party administrator (TPA) to a different third party administrator and internal operations on the Facets system. The Claims were designated to transition to a different TPA and it was agreed to transition the Customer Service functions to internal operations. Claims backlogs had been growing, the operations were out of compliance and the volume of both provider and customer calls were increasing due to the lack of performance. Our client wanted to immediately reduce the backlog in claims, improve the accuracy of claims processing, respond to incoming inquiries, bring the operations back into compliance and complete the transition of these functions.

Engagement Highlights

  • Industry:
  • Health Insurance
  • Client:
  • A National For-Profit Health Benefits Organization
  • Assignment:
  • Oversee and develop relationships at the first TPA while assessing the current situation
  • Map and understand the current processes in place at the first TPA
  • Establish processing requirements
  • Oversee the transition from one TPA to the other and internally
  • Develop and implement tracking and reporting to monitor status and results
  • Reduce backlog, improve processing accuracy and gain compliance
  • Complete the transitions
  • Approach:
  • Acted as the point of contact for all transition activities
  • Assisted in the development of requirements, new processes and reporting mechanisms
  • Immediately focused on claims backlog reduction and call triage activities
  • Actively worked with management and associates to address day-to-day requirements while building new processes for the new TPA and internal operations
  • Coordinated with Compliance and federal agency to report on transition activities
  • Duration:
  • 6 months


  • Created and implemented a consistent, accurate, timely and compliant claims process.
  • Provided interim leadership to oversee claims and customer service transition activities
  • Reduced claims inventory and improved accuracy and timeliness of claims payment
  • Provided ongoing reporting of all outstanding claims items on a daily basis
  • Developed ongoing reporting and performance monitoring for new TPA and internally absorbed functions
  • Assisted in development of vendor requirements and Facets negotiations
  • Successfully transitioned all claims and customer service processes

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