The TPA's job
A third-party administrator (TPA) is the firm a self-funded employer hires to run the operational machinery of its health plan. The employer holds the risk and sets the plan design; the TPA executes:
- Claims processing and adjudication — receiving, pricing, and paying provider claims against the plan document
- Network access — renting provider networks (or supporting direct contracts and reference-based pricing arrangements)
- Member services — ID cards, eligibility, the phone number on the back of the card
- Compliance support — plan documents, required notices and filings, and coordination under the ERISA framework that governs self-funded plans
- Reporting — the utilization and claims data that makes the whole self-funded proposition work
- Vendor coordination — connecting stop-loss carriers, PBMs, care-management programs, and point solutions into one functioning plan
Large insurance carriers also sell these services to self-funded employers under ASO ("administrative services only") arrangements — same concept, carrier-owned. Independent TPAs compete on flexibility and service; ASOs compete on network scale and brand familiarity.
How TPAs are paid — and why it matters
TPAs typically charge a per-employee-per-month (PEPM) administrative fee, with possible add-ons for services like case management, subrogation recovery, or custom reporting. That fee structure is refreshingly transparent compared to fully insured premiums — but it puts the burden on the employer to evaluate what's included, what's à la carte, and where incentives point.
Questions that reveal a lot in TPA selection:
- Who owns the claims data, and how quickly and completely can the employer get it?
- How are out-of-network claims priced, and who keeps any savings from repricing?
- Can the TPA administer non-standard plan features — direct contracts, reference-based pricing, or added benefits like telehealth with in-home diagnostics?
- What does implementation of a new point solution actually take — file feeds, eligibility, member communications?
That last one matters more each year: the modern self-funded plan is a stack of specialized components, and the TPA is the integration layer. A TPA that makes adding a claims-reducing benefit easy multiplies the plan's cost containment options; one that treats every integration as a change order quietly taxes them.
TPA vs. broker vs. carrier: who does what
The roles get conflated constantly, so, plainly:
- The broker or consultant advises the employer — market strategy, vendor selection, renewal negotiation. They work for the employer.
- The TPA operates the plan — claims, service, reporting. They also work for the employer.
- The stop-loss carrier insures the employer against catastrophic claims (see stop-loss explained).
- Point solutions — telehealth, in-home care, care navigation, PBM — plug into the plan through the TPA's rails.
In a fully insured plan, one carrier bundles all of this invisibly (and keeps the data). Unbundling is what gives self-funded employers leverage — and it's why choosing each component well, starting with the TPA, is the real work of self-funding.
Where benefits like EZaccessMD fit
Claims-reducing benefits live or die on clean administration. EZaccessMD is delivered as an employer-sponsored benefit alongside the medical plan: eligibility comes from the employer's census, members get 24/7 telehealth with a physician callback within the hour, and when a case needs evidence, a technician brings portable X-ray, ultrasound, EKG, lab, and rapid-test equipment to the member's home — at a $0 copay.
For the plan, that means avoidable ER and urgent care episodes resolve outside the claims system entirely. Employers and brokers evaluating the math can start with the ROI calculator or review modeled plan savings.