No broker or employer is expected to know every question in this series, or what every answer means. I have written them out so you can use them. Putting them together, knowing which threads to pull and what one answer means next to another, is the work I do with plans and brokers in Under the RFP.
Pharmacy data and accumulators
Some TPAs receive only summary pharmacy data, and not all load individual pharmacy claims. Ask what the setup actually is. Medical-only reporting can be simpler, especially with a direct broker and PBM relationship and a clean accumulator exchange. The vetting question is what your setup will be, so you can decide whether it fits.
Then ask about frequency. Ask how often accumulator files move between the TPA and the PBM, then ask what a member experiences in the gap. The member-facing failure looks like this: a member meets the deductible on medical claims, the file has not reached the PBM, and the member pays a copay on an expensive drug. Ask how the TPA handles that case.
Also ask whether a met deductible in one tier applies toward another, so a member who met a lower-tier deductible owes only the difference.
Midyear groups and deductible credits
When a group arrives midyear, who collects prior accumulator data, in what format, how is it loaded, and how fast? Ask for real accumulator data from the prior carrier or TPA. A screenshot of one member’s explanation of benefits is not data. Ownership of this process is often unclear on level-funded business, so settle it before the effective date.
Stop-loss: who submits, who tracks, who chases
Stop-loss is where a single large claimant can strain an account. Ask:
- Who prepares and submits the file when a member reaches the specific deductible, or when the group reaches its aggregate?
- How are high-dollar claims tracked as the group approaches a threshold?
- Does the TPA tell the broker and group when a claimant is nearing the specific deductible, or only after?
- How are reimbursements followed up, given that carriers scrutinize large claims closely and payment can take time?
Smaller groups carry a particular risk: routine claims can adjudicate but sit unpaid when one large claim drains the claims account before stop-loss reimburses it. Ask how often you would hear about it and what triggers an escalation. Ask for an escalation process and for the broker to be copied on submission correspondence.
Cash pay solutions
A “cash pay” capability is a claim to unpack. Pharmacy versions are simple. Medical versions carry the risk:
- Scope creep. A negotiated rate for an imaging study may not include the read, or the provider may bill a different procedure. How is expanded scope handled?
- Double payment. A provider agrees to cash pay and then also bills the network. How does the TPA prevent and reconcile that?
- Stop-loss approval. Has the carrier signed off? A rate below network can still be denied later if the carrier never reviewed the arrangement.
- Card-based programs. Who approves the load, and are the payments inside or outside the plan for accumulator purposes?
Frequently asked questions
What is an accumulator file?
A data file that tells each system how much a member has already paid toward the deductible and out-of-pocket maximum.
Why does stop-loss tracking matter before a claim hits the limit?
Early visibility gives the group time to plan, and gives the TPA time to assemble documentation.
Is cash pay inside the plan?
It depends on how the TPA structures it, so ask the TPA how cash pay counts toward accumulators and whether stop-loss recognizes it.