Quarterly Review Agenda
- 1Claims processing: Accuracy rate, turnaround time, pending claims
- 2Utilization management: Prior auth approval rates, case management outcomes, UM savings
- 3Member services: Satisfaction score, call volume, complaint resolution
- 4Analytics: Key cost drivers, population health trends, program effectiveness
- 5Compliance: ERISA filings, ACA compliance, HIPAA incidents
- 6Issues and escalations: Any problems with TPA performance or service
- 7Next quarter priorities: Planned improvements and initiatives
Performance Improvement Plans
TPAs who consistently miss performance targets should be placed on formal performance improvement plans (PIPs). A PIP defines specific performance targets, a timeline for improvement, and consequences for continued underperformance (including contract termination). PIPs signal to the TPA that performance accountability is real.
Annual Scorecard
IQ Insight
An annual TPA scorecard provides a comprehensive view of TPA performance over time. A scorecard that tracks claims processing accuracy, utilization management effectiveness, member satisfaction, and analytics quality across multiple years reveals trends that quarterly reviews miss. A TPA whose performance is declining year-over-year needs to be replaced — even if they are meeting quarterly targets.