Strategic Plan and CIO for a Large TPA in a Small Group Market
Business Problem:
The Company and its subsidiaries is a privately held insurance brokerage firm and Third Party Administrator (TPA) for employer sponsored self-funded health benefit plans. Over the past several years, The TPA has enjoyed significant growth, increasing the count of managed employee lives to over 150,000. With the growth of the business came requirements for adaptive and scaleable systems that can supplement and enhance the business processes that they support.
The problems facing the TPA from an operational standpoint were:
- Redundant, inconsistent, and inefficient business processes
- A lack of data integrity
- No access to information
- System adaptability and scalability
- Inefficient communication mechanisms
- Lack of effective electronic data interchange mechanisms
The TPA required an Information Systems Strategic Plan to provide a guide for the implementation and integration of information systems to support and enhance business processes now and into the future. The following list highlights the major goals of the plan:
Create a unified and efficient business process that eliminates all double entry of information Facilitate the automation of the business processes Establish accurate means for obtaining information to assist in decision support and analysis Provide the technology infrastructure required to meet the changing requirements of the industry
Solution:
RESolutions Consulting, acting as the CIO, developed the IT strategic plan. The plan provided an overview of the current environment, identified the business issues and concerns, and defined the future business model integrated with modern technology. The plan then recommended new systems development, identified the third party software needed to achieve better workforce communications and collaboration, and defined the needed technology infrastructure and IT staffing requirements. Finally the plan provided implementation recommendations, costs, and resources.
Return on Investment (ROI):
The following is a partial list of the improvements expected as a result of the study and plan:
- Improved quality and processing time of all operations and supporting functions by eliminating all redundant data entry.
- Improvement in operating performance related to manual and paper-based processing that will be automated or streamlined through improved information systems. For example:
- Implement claims EDI and claims auto adjudication systems to auto-adjudicate 40% of all claims and allow claims processors to process an average of 175 claims/day.
- Auditable accuracy and validity of data and a reduction in redundant data entry to non-interfaced systems and applications, currently resulting in errors and omissions and increased processing time.
- Enhanced and expanded management reporting and decision support capabilities. For example: NY
- Surcharge, HIPPA, claims EDI, PPO Management, e-mail, electronic interchange of information, marketing and customer services through the Internet, etc.
