Important: How Your Broker Should Handle TPA Claim Issues

You're not alone if you’ve received a year-end list of unresolved claims from your TPA with vague instructions or missing follow-through.

Here’s what your broker and TPA should do to prevent unnecessary costs—or added stress for your plan members.

1. Get the Full Story

For every claim in question, you need:

• Dates of Service: When were these claims incurred?
• High-Cost Claimants: Are any of the pending claims tied to a member with large claims that might be eligible for stop-loss reimbursement?
• Activity History: What has already been done to resolve these claims? Specific dates, outreach attempts, and call notes should be provided.

2. Press for Accountability –

While there are many reasons that claims pend for additional information, these are three we have seen lately.

• Medicaid Claims: If diagnoses are invalid, why not deny the claims? Is dual coverage in play?
• DME Claims: Why was rental equipment approved if the contract requires purchase? Was this caught during pre-certification? Whose error is it?
• Medical Records: When (and how often) were records requested? Are delays documented?
• Member Communication: Have members been informed of gaps or issues?

3. Protect Stop-Loss Compliance

Your broker should ensure the TPA provides all necessary documentation promptly to meet stop-loss policy requirements. Inaction here shouldn’t jeopardize your reimbursement or cause any additional stress to your plan members.

4. Demand Proactive Solutions

Claims requiring “additional information” shouldn’t turn into year-end chaos. Your TPA should outline exactly what’s missing and their timeline for resolution. Anything less signals mismanagement—or a lack of urgency.

If these actions aren’t already happening, it’s time to hold your TPA and broker accountable. Whether that means scheduling a call, creating a clear resolution plan, or ensuring your stop-loss coverage stays intact, now is the time to step up.

P.S. Small claims mishandled today can become big problems tomorrow. Make sure your TPA and broker are solving issues, not just observing them.