How to Select the Right TPA: A Strategic Guide for Tribal and Governmental Employers
For self-funded health plans, the Third Party Administrator (TPA) is more than a processor—it’s the operational core of your plan’s success. Claims accuracy, member experience, compliance risk, cost control—every one of these hinges on your TPA’s capabilities and integrity.
At Atria, we’ve seen too many employer groups—especially tribal and governmental organizations—inherit misaligned TPAs that introduce risk and complexity. That’s why we lead a structured, no-conflict TPA selection process designed to make your decision easy, defensible, and future-proof.
Why the TPA Decision Matters So Much
TPAs control how your money is spent. They adjudicate claims, answer member questions, produce your reporting, and often serve as the front-line communicator for your benefits strategy. When this vendor is misaligned, the impact shows up quickly:
- Payment errors and overcharges
- Delays in eligibility updates or ID card issuance
- Outdated technology with poor visibility
- Hidden incentives tied to reinsurance, pharmacy, or networks
Worse, many employers don’t discover these issues until a crisis forces them to look under the hood. That’s why the selection process must go deeper than price quotes and presentation decks.
Atria’s Structured Selection Process
Our broker-led TPA selection process includes:
- Detailed Requirements Analysis – We define what you need across claims, tech, stop-loss coordination, and cultural fit.
- RFP Drafting & Vendor Screening – We issue and score detailed RFPs using a proprietary evaluation rubric.
- Claims & Reporting Demos – You see how claims are processed, how errors are handled, and what reporting access you’ll actually get.
- Fee Clarity – We identify where fees are buried (e.g., network access, audit services, shared savings) and create true apples-to-apples comparisons.
- Renewal Performance Reviews – Audit how TPAs handled their renewals using actual redacted renewal samplings.
This process lets decision-makers stay focused on strategy while we vet the technical details that often go overlooked.
7 Criteria Every Employer Should Evaluate
We’ve identified seven categories that separate high-performing TPAs from underwhelming ones:
- Claims Accuracy: How often are claims paid incorrectly? What audit controls are in place?
- Member Service: Are calls answered promptly? Are employees getting real help or script-readers?
- Technology & Access: Can HR teams and members get real-time visibility into claims and eligibility?
- Data & Analytics: Does the TPA offer dynamic dashboards and reporting? Are BI tools included?
- Compliance Readiness: Can they handle plan document updates, ACA filings, and appeals properly?
- Stop-Loss Integration: Are they aligned with your stop-loss carrier, or creating gaps in reimbursement?
- Fee Transparency: Are fees carved out across services? Is there clarity around PBM or vendor rebates?
What Can Go Wrong with the Wrong TPA
We’ve worked with clients who inherited TPAs that:
- Allowed $100k+ in overpayments to pass through undetected
- Provided delayed or error-ridden data to their actuaries at renewal
- Refused to integrate with preferred PBMs or carved out specialty drug vendors
- Missed stop-loss filing deadlines, leaving the employer exposed
Each of these outcomes was preventable—and each was resolved by replacing the TPA through Atria’s review process.
Tribal-Specific Considerations
While most employers share common TPA concerns, tribal organizations face an added layer of complexity. These factors must be front and center when evaluating TPA partners:
- 638 Clinic Integration: Can the TPA coordinate effectively with your tribal clinic’s billing systems? Are they familiar with how IHS and contract health intersect with claims workflows?
- 340B Eligibility & Strategy: Do they understand the revenue potential of 340B drug pricing and how it must be reflected in claims and reporting?
- Sovereignty Respect: Does the vendor treat your governance structure with the respect and autonomy it deserves—or are they used to top-down corporate HR models?
- Custom Plan Documents: Can they support non-standard eligibility definitions (e.g., community member coverage)? Are they flexible with tribal enrollment data sources?
- Native Employee Experience: Does their service team understand the unique values and communication needs of Native communities?
- Medicare-Like Rate (MLR) Claims Management: MLR allows tribes to limit payment on certain claims to Medicare-equivalent rates. Does the TPA have systems in place to reprice eligible hospital and physician claims accordingly—especially when claims are tied to IHS referrals?
- Catastrophic Health Emergency Fund (CHEF) Integration: CHEF provides federal reimbursement to IHS for high-cost cases exceeding $25,000. Does the TPA coordinate effectively to track thresholds, collect documentation, and process reimbursement files timely?
- Payor of Last Resort Compliance: IHS is legally designated as the payer of last resort. Can the TPA manage coordination of benefits accurately and compliantly, ensuring that group health plans exhaust primary liability before triggering IHS funds?
Atria curates vendors who have proven performance in tribal settings. We ask the questions most brokers miss—and we cut vendors who treat tribal accounts as an afterthought.
Atria’s TPA Scorecard: The Tool That Makes It Easy
Every Atria client receives a custom scorecard comparing TPA finalists across 20+ weighted factors. We summarize:
- Technical performance and service quality
- Fee structures and rebate disclosures
- Integration with your existing partners
- Historical performance in similar employer types
- Tribal-specific capabilities (if applicable)
This lets tribal councils, HR, or CFOs make a confident, transparent choice—with Atria managing all of the legwork behind the scenes.
Final Word: The Right Partner Changes Everything
Your TPA can be a powerful ally—or a costly liability. Don’t settle. Whether you’re self-funded already or considering the move, Atria is ready to lead your TPA review and ensure your next contract delivers long-term value.
Let’s talk. We’ll show you exactly how we vet, compare, and implement the right fit for your people, your finances, and your future.
