Summit believes the primary responsibility of a Third Party Administrator (TPA) is to manage the Plan by effectively coordinating the components and monitoring the financial aspects. This enables the Plan to maintain costs while providing the best benefits to Plan members with the “Best in Class” vendors.
Summit is an “unbundled” TPA; meaning Summit does not own, nor is owned by any other vendor. Instead, Summit is proud to maintain strong, effective relationships with many reputable vendors. Summit believes that to own or limit vendor products under one roof—one-stop shopping—becomes the “fox guarding the hen house.”
If there is a preferred Plan vendor, Summit can work with them! Summit can also recommend a “Best in Class” Plan vendor for specific needs. In either case, the integration between Summit and other Plan vendors is seamless in effectively managing employee health benefits programs.
Quality Control is part of Taking Service to the Next Level. Summit manages Quality Control by performing internal random audits of Claims Examiners’ production as well as placing a set dollar release level upon the Claims Examiners, depending upon the expertise of the Examiner. The maximum level is $3,000 per claim, thereafter; the claim requires Claims Manager review prior to release. The Claims Manager release level is set at $11,000, thereafter; the claim is reviewed by an Officer prior to release.
Summit’s claims adjudication system detects and prevents duplicate payments by identifying criteria that matches and then the duplicate claims are set to deny. If partial criteria are met, the claim is set to pend for Claims Examiner adjudication.
Quality control doesn’t end with Summit monitoring the Examiners, or the system edits in place. Various firms are engaged to audit hospital bills, network repricing accuracy, and procedure coding accuracy. These firms are specialist in the specified field at recovering or saving the client’s Plan dollars. These firms assess a percentage of savings for their services. Summit does not take any portion of the percentage of savings or assess any other fee for this service.
Putting the Pieces Together for You.