Employee Health Systems is a medical management firm and provider network serving self-funded ERISA and managed care patients since 1985. EHS is fully delegated by all of the health plans with whom it contracts to provide care. ACA Administrators, an affiliate of EHS, serves as the third party administrator (TPA) providing the administrative and claims management expertise for the PVP program.

Unlike most TPAs that only provide billing and claim-paying services, EHS and ACA are managed care companies, and as a result take on the added responsibilities of utilization management, case management, quality management and provider credentialing. In many TPAs, these functions are outsourced and subcontracted to other third parties. In managed care, it all resides under one roof. Thus, in addition to claims personnel, EHS and ACA employ physicians and nurses to oversee referrals, follow patients who go to the hospital, and perform other clinical activities and requirements.

Because EHS and ACA are so heavily involved in managed care, we perform to standards required by HMOs and other managed care regulators. For example, clean claims are required to be processed and paid within 30 days. Routine referrals must be processed within 3 business days. These more stringent protocols are not required in a typical TPA setting. However, at EHS and ACA, all business processes operate at the more stringent managed care levels.

EHS and ACA utilize a full-blown state-of-the-art HMO computer system, HealthTrio Xpress, which includes all of the functions of an insurance company (and hence, TPA), and is flexible enough to process multiple lines of business with multiple fee schedules. As a result, EHS and ACA are currently responsible for and take care of more than 45,000 people in multiple states. By already servicing this business, startup times, training and other expenses are reduced.