TPA’s & The Maytag Repairman

Cash-pay centric health plans are turning TPA’s into Maytag repairmen lookalikes. In this case the phone has stopped ringing by 90%………………

A cash pay, PCP centric health plan established January 2021 is working extremely well so far. Approximately 90% of total claims are settled in cash at pricing similar or better than Reference Based Pricing RBP) plans.

No patient responsibility and no balance billing issues. Significant savings off RBP fees. Strong buy-in from the medical community, including one hospital system in particular.

The diagram on the right is an illustration of how a cash pay, PCP centric plan is structured.

We receive daily claims data. Below are three of yesterday’s claims:

Total knee replacement $16,357.86 (120% MC)

Sleep study $850 (92% MC)

Heart catherization $4,,043.73 (139% MC)

If these claims had been paid through a typical managed care (PPO) plan the pricing would be significantly higher which of course would necessarily have to be factored in on the cost of healthcare insurance.

Compared to PPO plans the savings in healthcare insurance costs can be as high as 50% and more.

And where is the TPA these days? Living the good life with family and friends, somewhere on a sunny beach in South America sipping umbrella drinks…………. is a specialty company in the benefits market that, while not an insurance company, works directly with health entities, medical providers, and businesses to identify and develop cost effective benefits packages, emphasizing transparency and fairness in direct reimbursement compensation methods.