Guides
The questions to ask, and what a good answer sounds like.
Practical guides to claims, pharmacy, compliance, stop-loss, and plan design, written to be useful whether or not you ever work with us. Several are structured so you can take them into a finalist meeting and use them on any administrator, including this one. Each shows when it was last reviewed.
- 2026 HIPAA Security RuleBuilt to it, not retrofitted
- AES-256 encryptionAt rest and in transit
- Immutable audit logs7-year retention
- SOC 2 Type IIIn progress, and we say so
- Clearinghouse-ready EDIClaims in, remittances out
All guides
How TPAs Actually Make Money: The Nine Revenue Lines
Your administrative fee is one of nine ways a third-party administrator can earn from your plan. The other eight rarely appear on an invoice. Here is each one, how to spot it, and the question that surfaces it.
Switching TPAs: What Breaks, and How to Sequence It
The honest version of a TPA transition for self-funded employers: what actually breaks, what the incumbent controls, the run-out decision, and the sequence that keeps members from feeling any of it.
What Makes a TPA Modern in 2026
Modern is not a portal refresh. Six structural tests that separate a genuinely modern third-party administrator from a legacy platform with a new front end, and how to verify each one.
Pass-Through PBM vs. Spread Pricing: What Your Pharmacy Benefit Is Hiding
Where traditional PBMs make their money (spread pricing, retained rebates, formulary incentives), and how a pass-through model removes those conflicts for self-funded plans.
Reference-Based Pricing, Explained for Self-Funded Employers
How RBP prices claims from Medicare-anchored benchmarks instead of network discounts, what happens with balance bills, what it does to stop-loss premiums, and when it's the wrong fit.
Self-Funded Health Plans: The Complete Guide for Employers
How self-funded health plans work, why employers switch, what a TPA actually does for you, the numbers worth watching, and how to tell if self-funding fits your company.
COBRA: The Compliance Risk Your TPA Carries for You, and How to Verify It
Missed COBRA notices and wrong premiums create legal liability that lands on the plan sponsor, not just the administrator. Here's what airtight COBRA administration looks like.
Denial Management: What Your TPA Should Be Doing, and What to Demand
Half or more of denied claims are recoverable, yet most returned claims are never resubmitted. Here's how to tell whether your TPA's denial management protects your plan, or bleeds money you never see.
EDI: The Invisible Plumbing That Decides How Fast Your Claims Get Paid
X12 EDI is how claims, payments, and eligibility actually move. Most plan sponsors never see it: but its quality shows up in payment speed, provider friction, and how fresh your reporting is.
The 2026 HIPAA Security Rule: What It Means for Your Health Plan
The 2026 HIPAA Security Rule eliminates 'addressable' safeguards. Every control is now mandatory. Here's what plan sponsors should demand from their TPA before enforcement begins.
Stop-Loss Insurance for Self-Funded Plans: What Employers Need to Know
Stop-loss insurance protects self-funded employers from catastrophic claims. Understand specific vs. aggregate coverage, attachment points, and what your TPA should be doing for you.
Auto-Adjudication Rate: The One Number to Ask Your TPA For
Most administrators auto-adjudicate 40-60% of claims; the best reach 85-95%. Here's why that gap shows up in your plan's cost and member experience, and how to evaluate the answer you get.
The Technology Behind Your Health Plan: Evaluating a TPA's Stack in 2026
Your administrator's technology decides your claim accuracy, reporting speed, and compliance posture. Here's how to see through the demo and evaluate what a TPA actually runs on.
How Automated Claims Adjudication Cuts Processing Time by 90%
A claim that touches seven people takes 3 to 14 days and picks up an error at every handoff. The same claim finalizes in under two seconds when the plan is codified as rules. Here is what actually happens in between.
AI-Powered Medical Coding Validation: Catching Errors Before They Cost You
Upcoding, unbundling, and invalid code combinations are found in 5 to 10 percent of claims. Catching them before payment keeps the whole dollar. Recovering them afterward returns a fraction and costs a provider relationship.
Real-Time Eligibility Verification: Why Sub-Second Response Times Matter
Slow eligibility checks delay care and increase denials. Learn how real-time eligibility verification with accumulator tracking transforms TPA operations.
Use them on us
Run the evaluation checklist on SmartTPA.
The evaluation guides work on any administrator, this one included. Ask us the twelve questions, then send a claims file and check our answers against your own data.