TPA Due Diligence Reviews
SERVICES
TPA Due Diligence Reviews
Claims Consulting Partners provides experienced and qualified TPA Claims Due Diligence Reviews.
A TPA Claims Due Diligence Review is a structured technical and operational assessment of a prospective or incumbent Third-Party Administrator (TPA) to determine whether the claims operation meets required best practices, contractual requirements, and regulatory standards for insurers, reinsurers, self-insured programs, captives, and RRGs.
Our reviews provide a clear understanding of a TPA’s capabilities, performance, and overall effectiveness in managing claims operations.
What We Evaluate
Our TPA Claims Due Diligence Reviews focus on the core areas that drive claims quality, operational performance, and compliance, including:
Regulatory Compliance
Operational Effectiveness
Management Experience & Governance
Claims Technical Quality
Technology & Reporting
Financial Oversight & Leakage Control
TPA Due Diligence Evaluation Areas
Our TPA Due Diligence Review process includes a comprehensive evaluation of the TPA’s organization, operations, and claims handling practices. These areas may be reviewed in full or segmented based on your organization’s specific needs.
- TPA Service Agreement
- Ownership and corporate structure
- Organizational structure (executive, management, technical, and support)
- Physical office locations and infrastructure
- Insurance (E&O, Fidelity Bond and P&C)
- Management knowledge, experience, and span of control
- Staff knowledge, experience, and authority levels
- Licensing and regulatory compliance
- Pricing structure and run-off provisions
- Technology and systems (claims and document management)
- Claims data export capabilities and processes
- Claims management and analytics reporting
- Remote access capability
- Claims best practices guidelines
- First Notice of Loss (FNOL) processes
- Litigation management procedures and guidelines
- Approved defense counsel and vendor panels
- Independent adjuster and appraiser management
- Workers’ compensation medical and disability management
- Legal and medical bill review processes
- Estimating software (property and auto)
- Payment processing and loss fund accounting procedures
- Staffing levels, workloads, hiring practices, and turnover
- Claim volume by client
- Business continuity planning
- Large loss reporting procedures
- Diary management procedures
- Coverage verification and recovery procedures
- Catastrophe claim processes
- Medicare reporting and OFAC compliance
- Reference checks and vendor management
Our Approach
Our TPA Due Diligence Reviews are designed to provide a structured and objective evaluation of claims operations, with the flexibility to be tailored or segmented based on your specific objectives.
We also support TPA pre-qualification and can assist with RFP preparation, review, vendor selection, and recommendations. Our team provides guidance on pricing structures and future run-off provisions to support informed decision-making.
Each engagement delivers clear insights into TPA performance along with practical, actionable recommendations to help you select, evaluate, and optimize your claims administration partners.
Interested in TPA Due Diligence Reviews?
Contact us to learn how our TPA Due Diligence Reviews can support your organization in selecting and managing effective claims administration partners.