BRI Participant Services connects with thousands of valued employees every month. Call topics range from account login troubleshooting to eligibility confusion questions to claim inquiries. They hear it all! At BRI, we actively invest in our participants’ health and wellbeing. We strive every day to create the resources you need to maximize your savings and peace of mind.
Lately, we’ve seen an uptick in questions around the roles of responsibilities of your company’s broker, your TPA (that’s us), and your health insurance provider. So what’s the difference between the three? And where does your health insurance carrier play into this? Let’s break it down.
What is a health insurance carrier?
A health insurance carrier administers your health insurance plan. It will pay your healthcare provider for the services they provide to you, assuming the service is eligible to be covered and your cost-sharing responsibilities are met.
An insurance carrier is a risk-bearing entity. Once the carrier issues an insurance policy, it takes on the financial risk and responsibility to pay the claims incurred under that policy.
What is a TPA?
A Third-Party Administrator (TPA) is a company that aids with plan design, launch, and ongoing participant service support under a contract of your employer. They:
- Administer your benefits (i.e., adjudicate claims, issue ID cards, handle customer service, etc.).
- Provide customer service to plan participants.
- Review and process claims to identify fraud, waste, and billing mistakes from healthcare providers.
- Provide enrollment assistance to the employer, including eligibility verification for employees and COBRA assistance for qualifying terminated individuals or individuals with reduced hours.
TPAs provide some substantial advantages to ensure your employer provides excellent healthcare benefits while protecting their bottom line. Here are some things to consider.
- TPAs are not typically owned by larger parties like hospital systems or insurance carriers.
- TPAs have the advantage when it comes to developing a customized plan to maximize savings and minimize risks.
- A TPA’s success is directly tied to their clients’ successes. It is therefore much more likely to be service-oriented to help their clients meet their goals and objectives. Employers will generally find that Carriers operate with rigid rules and policies, while quality TPAs are partners in their success.
- TPAs build partnerships that benefit each group’s unique geographic, quality and cost preferences. They have the ability to contract with multiple networks or vendors. This gives employers the flexibility needed to discover cost savings opportunities and have increased control over their plans.
When to call your Insurance Plan Provider vs. when to call your TPA
Check out our table to better understand who to contact depending on your situation.
|When to call your insurance plan provider||When to call your TPA|
|• Questions on medical claims||• Commuter information|
|• Health plan coverage questions||• Pre-tax claims|
|• Explanation of benefits||• Specialty account reimbursements|
|• What counts towards your deductible||• Open enrollment : FSA/ HSA/ HRA/ VEBA|
|• OTC coverage questions|
HIPAA & PHI Limitations
As a TPA, particularly for Beniversal Card substantiation requests, participants often want us to “just speak to their insurance company if we need a receipt.” We get it. Sometimes pre-tax benefits (and the regulations around your plan) can get confusing. Unfortunately, as a TPA, we’re not allowed to discuss the information that you submit to us with anyone… (including your health insurance). Heads up: We only see claim and card swipe data.
The same is true for your insurance provider. They aren’t allowed to talk about your medical claims due to HIPAA and PHI restrictions.
In a magical non-regulated world, we would have a golden hotline directed right to your providers, but we don’t and can’t. There isn’t a health industry love circle where we can all share the data we want and need. This unfortunate (yet necessary) setup makes you, the participant, sometimes feel like a kid stuck in the middle of divorced parents acting as a middle man. (Sorry for this strange comparison, but HIPAA restrictions are for your own good…and your privacy!)
What is a broker?
A broker acts as a liaison between your employer and the insurance company. They:
- May maintain relationships with a variety of insurance companies but are not employed by any of them.
- Advocate on your company’s behalf to help them achieve the appropriate coverage for their needs and within their budget.
- Keeps your employer’s interests top of mind when dealing with insurance companies, making the process as streamlined as possible.
Employers, employees, and brokers alike have come to trust BRI and rely on us for their tax-free benefits needs.