Third Party Administrator (TPAs) owned by insurance giants have an inherent conflict of interest arising from their pre-arranged contracts with providers which binds their loyalty to their provider networks rather than loyalty to their self-funded client. Moreover, because the Affordable Care Act has placed a cap on the profit margins of insurance companies, they are looking for savings elsewhere, which have included increasing all premiums (including reinsurance premiums), increasing TPA fees, and cutting costs by reverting to fully automated, robotic systems using overseas call centers which also serve as an obstacle to efficiently process claims accurately and timely.
What Separates Us?
Any CFO or key employee responsible for the financial responsibility of any business understands the critical importance of managing your own cash flow. If a vendor is going to strip away your control over cash flow they had better have a compelling reason that ultimately saves the business money. But what happens when an insurance giant strips away control of cash flow and charges way more than necessary for the services they’re offering to the same business? That is exactly what is happening right now and it is happening to the second most expensive budget item for any business or tribal enterprise.
"Medicare-Like Rates" (MLR) for Qualifying Tribal Members
Since July 5, 2007, federal law has provided that Medicare participating hospitals must accept as payment in full, for all levels of care furnished, no more than "Medicare-Like Rates" ("MLR"), as outlined in federal regulations, for services authorized by a Tribe or Tribal organization carrying out a CHS program of the IHS. [See 42 C.F.R. § 136.30; 42 U.S.C. § 1395 cc(a)(i)(U)]
FirstNation Health serves Indian Country as Tribal Insurance Advocates to deliver MLR pricing on behalf of our tribal partners— something most of the multi-billion dollar insurance giants simply do not offer. After pre-certification, FirstNation will deliver the following:
- MLR pricing on our customized benefit cards;
- An acknowledgment form sent to the provider where the provider acknowledges MLR pricing;
- A Utilization Review/Case Management strategy that re-prices eligible claims available for MLR as a safety net to capture MLR if it wasn't provided at the time of billing.