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# The PBA Advantage
# Savings
[## Proven Process. Proven Results.
It's more than just network discounts. It's the quality of the process, realizing meaningful savings for the plan, and creating better outcomes for members.
# Service
[## #1 Rated TPA - 4.8 Stars
Need we say more?
# Solutions
[## Problem Solving Fueled by Experience
More than 35 years in business has taught us what REALLY works and what does not.
### Company
### Users
### Contact
* 630-655-3755
* PO Box 4687
  Oak Brook, IL 60522
### Connect
©  Professional Benefit Administrators. All rights reserved.
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# Download Machine Readable Files
Below are links to Machine-Readable Files (MRFs) as required by the Consolidated Appropriations Act (CAA) & Transparency In Coverage regulation.
These files are supported and maintained by each individual network. Professional Benefit Administrators does not assume any legal liability or responsibility for the accuracy, completeness, or usefulness of any information.
* BCBS - Catholic Diocese of Rockford (grandfathered, no MRF available)
[## Innovative Solutions Powered by Proven Partners
These targeted strategies can reduce costs in high spend categories while promoting positive patient outcomes.
# Managed Care
[## Balance Cost Control with Care Options
Learn more about our cost, utilization, and condition management strategies.
# Claims Management
[## Make an Impact to the Plan Spend
Beyond applying the provider discount, PBA’s claim integrity services result in additional plan savings.
# Innovative Solutions with Best in Class Partners
# Complex Medical Condition Management
## The Mayo Clinic Complex Care Program
Brings together a team of clinicians that offer answers and treatment plans for complex, rare, or undiagnosed conditions through a cost-effective approach.
# Musculoskeletal Cost Management
## Reduces Musculoskeletal Spending
Achieve better patient outcomes through more accurate diagnoses and effective treatment options.
# Specialty Drug Infusion Management
## Save on Infused Specialty Drugs
Manages the costliest medications in the specialty drug category, where the price point is very close to the Average Wholesale Price.
# Diabetic Supplies and Coaching
## Diabetic Supplies and Coaching
Provides diabetic members with lower cost, direct-to-home diabetic supplies and diabetic health coaching services.
# Managing Multiple Chronic Conditions
## Reduce Future Healthcare Costs
A solution for managing multiple chronic conditions where behavior changes produce long term results.
PBA finds the appropriate customer satisfaction balance between cost control and steering members to the care they need.
## Cost Management is Accomplished Through
### Strong Precertification, Utilization Review, and Care Coordination Programs
Offering members peace of mind that services will be covered by the plan before the services are incurred.
### Data Mining
To identify and manage chronic conditions when early intervention and education can help reduce long-term costs.
### Specialty Condition Management Programs
That help control the costs of high-priced medical treatments, such as cancer, transplants, and dialysis.
The core of all TPAs but where PBA differentiates itself.
# Creative Plan Designs
We can administer many types of plan designs; including narrow networks, direct contracts, or tiered plan designs with concierge services to drive steerage.
# Medical Bill Review
Review every claim with a goal of verifying the appropriateness of the services billed and compliance with national billing code standards.
# Out-of-Network Discounts
PBA achieves an average discount of 58.1% on 98% of out-of-network claims.
# Selective Auto Adjudication
To maximize plan cost control, we place every claim on hold pending Claim Analyst review if it is over $10,000 as well as all hospital services, services requiring pre-certification, services resulting from potential third party liability, or high cost drug claims.
# Member Advocacy
[## Outstanding Member Advocacy
Our Member Advocates provide personalized, empathetic service to every caller and have a first call resolution rate of 98%. The PBA team provides reassurances and answers questions thoroughly to provide peace of mind.
# Third-Party Administrative Services
[## Flexible and Meaningful Self-Funded Administrative Services
Our prime objective is to improve outcomes for our clients by helping them save money while still taking care of their most important asset—their employees.
# Outstanding Member Advocacy
The hallmark of PBA's superior service is our Member Advocacy team, which includes experienced professionals ready to serve our clients quickly and accurately. Our domestic call center has live Member Advocates answering all phone calls, not automated systems. We never trap callers in an endless phone carousel system. We fully understand that when callers reach out with a problem, they are often anxious for a resolution.
Our Member Advocates provide personalized, empathetic service to every caller and have a first call resolution rate of 98%. The PBA team provides reassurances and answers questions thoroughly to provide peace of mind. Likewise, each employer group is assigned to and supported by resolute account teams comprised of associates with an average of 20 years of industry experience.
## What People Are Saying About Our Service
We offer flexible and meaningful  administrative services to employers that promote engagement and a culture of wellness for plan members, including:
All third-party administrators aren't created equal. At PBA, our prime objective is to improve outcomes for our clients by helping them save money while still taking care of their most important asset—their employees.
## We empower you to navigate the complex healthcare system, and we'll exceed your expectations while doing it!
# Health Plan Cost Analytics
As healthcare costs continue to rise, employers need to know that they are getting the most out of the company’s benefit investment.
PBA helps our clients understand and control benefit costs by consolidating all data in one platform and creating health cost transparency. Detailed benefit usage and health plan analysis tools allow for smart and effective benefit plan design and monitoring.
Proven data analytic technology transforms health plan data into actionable information, and this information can be used to achieve the following goals:
* Determine where your healthcare dollars are being spent
* Create more efficient plan design
* Estimate future costs
* Predict risk and costs
* Benchmark plan performance
* Test hypothetical scenarios
* Population risk management
## Want More Sales Information?
Are you a broker or employer group that is interested in what you are reading? Submit your information and a sales representative will contact you to give you more information about this service! Want to talk to a sales person direct? Call us at 630-655-3755.
# Pharmacy Benefit Manager (PBM) & Drug Card Programs
Comprehensive health plans include pharmacy benefits to cover prescription drugs. It's a vital part of every benefit package because prescription drug costs make up a large portion of the claim costs of a health plan. PBA offers prescription plans through preferred Pharmacy Benefit Management (PBM) partners. Our partners offer innovative programs such as specialty drug carveout, international sourcing, copay/patient assistance programs with true member out-of-pocket reporting, and alternate funding sources.
## What Is Pharmacy Benefit Manager?
PBM is an industry comprising a group of companies that serve as middlemen between pharmacies, drug manufacturers, and health insurance companies. They are responsible for securing lower costs for prescription drugs for insurance companies and those they insure.
## The PBA Solution
Pharmacy benefits can cost health plans and employers more than 20% of their total medical spend. It's never been more important to closely manage your pharmacy program, which is a critical component of PBA's pharmacy benefit best practices.
We engage an independent PBM consultant who provides feedback on PBM contracts, allowing our clients to discuss their contract language and terms with the PBM and achieve better prescription cost containment goals. To this end, our independent PBM consultant:
* Monitors PBM performance to ensure continued satisfaction;
* Conducts annual claims reviews to ensure PBM contracts adhere to the contracted Average Wholesale Price (AWP) discounts, dispensing fees, and rebate guarantees;
* Ensures each client is matched with the most cost-effective PBM for their unique needs;
* Renegotiates PBM contract terms and pricing as opportunities arise; and,
* Ensures clients have established the right management techniques by providing insight into PBM programs and trends.
We help you put the brakes on runaway prescription drug costs.
# Government Compliance
The regulation of most self-funded plans falls under federal law and state mandates don't apply. However, there are many provisions, and keeping up with government compliance can become complex. The greatest challenge for employers offering healthcare benefits today is understanding and complying with ever-changing government regulations. PBA takes the burden of regulatory compliance off the shoulders of employers.
## Regulations Overview
### ERISA
The Employee Retirement Income Security Act of 1974 is the primary law that applies to self-funded plans offered by private employers. The Employee Benefits Security Administration (EBSA) administers these standards and focuses on fiduciary duty. ERISA is the ultimate transparency and consumer protection law with considerable protection and structure for employers and employees.
### HIPAA
The Health Insurance Portability and Accountability Act of 1996 requires national standards to protect patients' sensitive health information from being disclosed without their knowledge or consent. The U.S. Department of Health and Human Services (HHS) issued the HIPAA Privacy Rule to address consumers' protected health information by covered entities, which include health plans.
### COBRA
The Consolidated Omnibus Budget Reconciliation Act of 1985 mandates insurance plans to give employees and their families the option of continuing their health insurance coverage for a limited period after leaving their job under certain circumstances. COBRA is a protection contained in ERISA.
### ACA
The Affordable Care Act of 2010, formally known as the Patient Protection and Affordable Care Act, was enacted to make affordable health insurance available to more people through premium tax credits. It also provides tax credits to certain small businesses that cover specified health insurance costs for their employees. The Center for Consumer Information and Insurance Oversight (CCIIO) oversees the ACA.
### Transparency Act
Health plan price transparency helps consumers know the cost of a covered item or service before receiving care. Beginning July 1, 2022, most group health plans and issuers of group or individual health insurance will begin posting pricing information for covered items and services. This pricing information can be used by third parties, such as researchers and app developers, to help consumers better understand the costs associated with their health care. More requirements will go into effect starting on January 1, 2023 and January 1, 2024, which will provide additional access to pricing information and enhance consumers's ability to shop for the health care that best meet their needs.
## The PBA Difference
PBA is uniquely qualified to assist clients in complying with regulatory requirements that impact employer benefit plans. We partner with law firms specializing in both ERISA & Non-ERISA Plans, and attorneys specializing in employee benefit plans and current ACA issues. PBA is dedicated to helping employers navigate the complex and changing regulatory landscape. We assist our clients with regulation compliance by:
* Assisting with ERISA, COBRA, HIPAA and ACA notices;
* Reviewing all plans for compliance;
* Providing guidance in making the plan compliant;
* Issuing timely notices of regulatory changes and upcoming compliance deadlines;
* Assisting with regulatory reporting to facilitate the payment of fees and taxes; and,
* Sponsoring regulatory training sessions for employers and their broker/consultant representatives.