Workers' Comp

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

MIN READ

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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.
 

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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.
 

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Assessment of Staffing Needs

Pre

Post 

30 RNs (supervisory and support staff)

20 RNs

  • Billable hours per RN per day: 5
  • Billable hours per RN per year: 1,255 year
  • Billable hours per RN per day: 7.5
  • Billable hours per RN per year: 1,882.5 year

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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

 

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Outcome

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

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Staffing Reduction Savings:
$4K Staffing cost savings
12,550 billable hours Productivity gained
63 Average business days saved per claim
$8,025 Average savings per claim
92% Return to work
 

 

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