Transforming a Third Party Administrator’s (TPA) Telephonic Case Management Program

Problem

A mid-sized national TPA was considering outsourcing its telephonic case management services to a third party. After evaluating their current program, including ongoing financial commitment to maintain clinical staff, a decision was made to request proposals from outside parties.
 

Solution

Aligning to the client’s vision, Enlyte created a customized early intervention telephonic case management program leveraging Enlyte’s risk identification tool for optimal case selection. The program was designed to ensure the TPA was provided a program that promoted injured employee advocacy, ensured timely access to quality care and reduced lost time days. Staffing needs were determined from a claims analysis that reviewed case durations, optimal caseloads and baseline productivity metrics.
 

Assessment of Staffing Needs

Enlyte’s Solution for This TPA Included the Following:

• Private labeled program
• Reduction in overall clinical headcount due to an increase in case manager productivity
• Dedicated telephonic case managers meeting state licensure requirements
• Customized employer workflows
• URAC accredited program
• Daily claims feed
• Electronic interface of case notes to the claim file multiple times per day
• Life of the claim risk modeling to identify and manage only those claims predicting or demonstrating the need for clinical intervention
• Elimination of costs associated with recruitment, hiring, retention, salary, benefits, multi-state licensure, certifications and continuing education
• Clinical dashboard for a transparent view into inventory, costs and outcomes

Outcome

The Third Party Administrator improved its bottom without disruption to claims staff or clients during the transition.