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.
Why this comes first
Sales conversations blur the basics. Two TPAs can both say “we handle everything,” while one adjudicates claims on its own platform and the other passes them to a partner behind the scenes. You cannot judge service, accuracy, or accountability until you know who is doing the work.
The baseline questions
- Claims adjudication system. What platform is it, and is it licensed from a software vendor, or proprietary (built and owned by the TPA)? Licensing is normal. If it is proprietary, keep probing, because every claims system has gaps and a newer one may still be building basics.
- Future changes. Do they plan to change or upgrade the core system in the next two to three years? Staying current is good, but migrations carry data risk. Ask what notice you would get and what window you would have to back up your data.
- In-house percentage. Ask for a number, then ask what sits in the remainder. Customer service, plan build, and claims processing can each be handled somewhere else.
- Back-office partners. Does another organization perform any back-office services for the TPA?
- Network access and aggregators. Some national networks set minimum life counts. A smaller TPA may reach those networks through an aggregator, which adds a step: the claim is repriced by the aggregator, gets the aggregator’s own codes applied, and returns to the TPA for adjudication. Ask which networks are accessed this way and how the TPA keeps configuration consistent.
Ask for true lives
Ask how many lives are administered in the TPA’s own system, excluding lives that sit inside an aggregator’s block. In one case I have seen, a TPA cited roughly 40,000 lives on a national network when that figure belonged to its aggregator and the TPA’s own count was about 3,000. Also ask whether the number counts subscribers or all covered members, and make them say which.
What the answers mean
Nothing here is automatically good or bad. A TPA that does everything in-house except one aggregated network is a different picture from one that adjudicates mainly through white-labeling. A younger TPA on a proprietary system may be agile and responsive, or it may be missing functionality your plan design needs. What matters is that you see which one you are evaluating, and that you test the system’s capabilities (Post 4) instead of assuming them.
Frequently asked questions
What does “white-labeled” mean for a TPA?
It means services delivered under the TPA’s brand but performed by another organization. It should be disclosed and counted separately from in-house work.
Does a TPA need to own its claims system?
No. Licensing or renting a platform is common. The question is how well they use it and what happens if they change it.
Why does a TPA’s true lives count matter?
They indicate the scale of the TPA’s own operation, how its service team is sized, and whether its network access is direct or aggregated.