Every mispaid claim comes out of your account.
The industry pays 5 to 10 percent of claims wrong. On a self-funded plan every one of those dollars leaves your balance sheet instead of an insurer’s. SmartTPA is the administrator built to catch them first.
- 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
How we get paid
Nine ways a TPA can make money off your plan. We take one.
One should sound like a marketing number. So here are all nine, including what we would charge if we charged it, and the question that surfaces each one. Every line below is a real way administrators earn from self-funded employers, and most of them are legal, common, and invisible on your invoice. Read the list, then ask your current administrator to go down it with you.
- We take
Administrative fee
One disclosed per-employee charge. This is the whole of what we earn, and it is the same number whether your plan has a quiet year or a catastrophic one.
- We do not
Pharmacy spread pricing
Billing the plan more than the pharmacy was paid and keeping the difference. Our pass-through PBM bills you directly, so those dollars never touch our books.
- We do not
Retained pharmacy rebates
Manufacturer rebates kept rather than passed on. Ours are reported and belong to the plan.
- We do not
Network access fees
A per-member charge for routing claims through a network, often paid back to the administrator as a rebate. We retain none of it.
- We do not
Cost-containment contingency fees
A percentage of whatever a vendor claws back after payment. It rewards finding errors late. We catch them before payment, which earns us nothing extra and saves the plan the whole dollar. Subrogation is the one place a specialist is genuinely required: an independent firm pursues the liable third party and takes a contingency out of what it recovers. You can pick that firm yourself, you see their rate, it passes through at cost, and we keep none of it.
- We do not
Out-of-network repricing markup
A margin added when an out-of-network claim is repriced. We add none.
- We do not
Per-claim and per-transaction surcharges
Charges per claim, per ID card, per report, per EDI file, usually in an addendum nobody reads twice. There are none in our agreement.
- We do not
Float on claim funds
Interest earned while holding a plan's pre-funded claim account. Your funding stays with you until claims are paid, so there is no float for us to earn.
- We do not
Undisclosed vendor commissions
Overrides from stop-loss carriers, clinical vendors, or pricing partners. We take no margin from any partner we contract, and every engagement carries CAA-compliant compensation disclosure.
Every line on that list except the first one pays more when your plan spends more.
That is the whole problem with how this industry is paid, and it is why an administrator can be genuinely helpful and still cost you money. Ours is the one line that does not move, which means the only way we grow is by keeping plans long enough that they renew.
See what the fee actually coversThe claims rerun
Find out what your plan overpaid last year. On last year’s claims.
Every argument on this site is testable against a file your current administrator already produces. So test it before you talk to us about anything else.
- What you send
- One claims extract. A standard file your current TPA, carrier, or clearinghouse already generates on request.
- What we do
- Reprice every line through our pricing engine and pass-through pharmacy model, the same path a live claim would take.
- What comes back
- A line-by-line report of what those exact claims would have cost here, medical and pharmacy itemized, with the difference shown per claim rather than as a headline percentage.
- What it costs you
- The work is ours and the report is yours, including the version where you decide to stay where you are.
- What we will tell you
- If the difference is not worth the disruption of switching, we will put that in writing. We would rather learn it now than at the finalist meeting.
Sample output
- Claims repriced
- 4,218
- Lines paid above plan terms
- 287
- Auto-adjudication on this file
- 92.4%
- Median adjudication time
- 1.4s
Illustrative structure of a rerun report, not a specific client and not a projection of your result. What yours shows depends entirely on what is in your file.
Where the money comes from
Lower spend, without making care harder to use.
Most cost-containment pitches reduce to raising the friction until members give up. These three come out of the plumbing instead, listed in the order they reliably pay off.
Pay the right amount, the first time
The industry mispays 5 to 10 percent of claims. Coding validation and automated edit checks run before payment, so the error is prevented rather than chased. This is the most reliable lever because it does not depend on anyone changing their behavior.
Take the spread out of pharmacy
Your Rx benefit runs through an independent pass-through PBM. The plan pays what the pharmacy is paid plus one disclosed fee, rebates are reported, and the PBM bills you directly, so pharmacy dollars never route through our books.
Take the margin out of administration
One administrative fee, disclosed in full. No per-claim surcharges, no undisclosed vendor compensation, no margin hidden inside the plan's own spend. What we earn does not go up when your plan spends more.
What actually changes
One system runs the whole plan. Here is what that buys you.
Adjudication, eligibility, portals, and compliance are one platform rather than a patchwork of aging vendor systems held together by people rekeying data between them.
You find problems while they are still cheap
Spend, utilization, and anomalies update as claims land instead of arriving 30 days later in a PDF. A high-cost claimant surfaces while case management can still change the trajectory.
Errors get caught before the money leaves
Coding validation and pre-payment edits run on every claim. Prevention keeps the dollar. Post-payment recovery gets a fraction of it back, pays a contingency fee for the privilege, and costs you a provider relationship.
Your pharmacy spend is what the pharmacy was paid
An independent pass-through PBM bills your plan directly and keeps no spread. Rebates are reported. Nobody between you and the counter earns more when the drug costs more.
The fee is the fee
One disclosed administrative charge, with no per-claim surcharges and no vendor compensation buried in the plan's own spend. Every dollar your plan pays, you can trace to a line.
HR stops being the benefits help desk
Members get cost estimates before care, live deductible status, and answers grounded in their actual plan document. The questions that used to reach HR get resolved before they are asked.
Your renewal conversation has numbers in it
Every claim and every decision is logged immutably for seven years. When you or your broker want to know why a claim paid the way it did, the answer is a record, not a recollection.
Before you ask
The questions we would ask in your chair.
You are new. Why would anyone hand you a health plan?
Fair, and we are not going to pretend otherwise. We are early, there is no wall of client logos on this site, and we are onboarding our first groups now. That is precisely why the first step is your own claims file and the second is a parallel run against your incumbent. You are not asked to take anything here on faith. You are asked to compare two numbers computed on data you already own.
Is software going to deny my employees' claims?
No. Administrative determinations follow the plan document (eligibility, covered terms, duplicates, timely filing) and anything outside those rules routes to a person. Medical necessity is never automated. Prior authorization and clinical review run through an independent URAC-accredited partner, and an appeal is heard by a reviewer who had no part in the original decision. Every automated determination is logged with its reason.
Switching administrators is a nightmare.
It is, and that is the honest reason most plans stay where they are. So nothing in the first two steps touches your live plan. The rerun is a file. The parallel run is a copy. Your current administrator keeps paying claims the entire time, and you decide with results in hand rather than a projection.
What is the catch on an analysis that costs nothing?
It costs us the work, which is the point. Repricing your actual claims is the fastest honest way to learn whether we are worth your time, and a report showing little difference is a result we would rather find early too. You keep it either way, including the version where you stay put.
Where does SOC 2 stand?
Type II is in progress. We write in progress because that is where it is, and an administrator that blurs this is telling you something about the rest of its answers. Encryption at rest and in transit, immutable audit logging, and least-privilege access are running now. We share security documentation under NDA during evaluation.
Do I have to leave my broker?
No, and we would rather you did not. Brokers place and renew most of the groups we work with. Yours keeps the relationship, keeps the compensation, and gets the disclosure and reporting that make the renewal conversation easier to have.
Read this before you call
Five situations where we are the wrong answer.
Every one of these is something we would tell you in the first meeting. Saying it here saves us both the meeting.
You have fewer than about 100 employees
Below that, a single catastrophic claim swings a self-funded year too hard to be comfortable. A level-funded product is usually the better bridge, and a broker who tells you otherwise is selling rather than advising.
You want the lowest administrative fee in the RFP
We will lose that comparison to administrators who make it back on spread, rebates, and contingency fees. The fee is not the cost. If the fee is the metric, the incumbent probably wins and we would rather not spend your finalist slot.
You need a national carrier name on the ID card
Sometimes that is a real internal requirement rather than a preference, and no amount of adjudication accuracy solves it. Better to know in the first meeting.
You want an administrator that never says no
We follow the plan document. When it excludes something, the claim is denied with the language that excluded it and instructions to appeal. If the expectation is that pressure changes outcomes, we will disappoint you.
Nobody will look at the claims data
Self-funding rewards attention. Not much, a quarterly review is plenty with reporting this current, but more than zero. If benefits are a set-and-forget line item, most of what we build goes unused.
How this goes
Three steps, and your plan does not move until the last one.
Nobody should change administrators on a promise. Each step here exists to give you evidence before you risk anything for the next one.
Rerun your claims
Send one claims extract. We reprice every line and return what the same claims would have cost here, medical and pharmacy itemized. You keep the report.
Nothing connects to your systems
Run us in parallel
Shadow mode processes copies of your live claims alongside your current administrator. Same claims, two answers, side by side, for as long as you want to watch.
Your plan does not change
Go live
Move the plan when the numbers have held up on your own data for long enough to be boring. Upload the plan document and census, confirm the configuration, and we prove it with test claims before the first real one.
You decide on evidence
Who it is for
One health plan, working for everyone it touches.
Employers fund the plan. Brokers place it. Members use it. Providers bill it. A plan that only works for the person who bought it does not stay working for long.
Employers
See every dollar as it moves, and stop funding the claims a legacy administrator quietly pays wrong.
See the detail
Brokers
Walk into finals with a number instead of a deck, and keep the group through renewal on reporting your client can read.
See the detail
Providers
Eligibility answered before the visit, clean claims cleared in seconds, and remittance you can read the first time.
See the detail
Members
What a procedure costs before it happens, where the deductible stands, and a claim that just works.
See the detailStart with your own numbers
Find out what your current TPA is costing you.
Send the claims file. We reprice every line and show you the difference. If it is not worth switching for, we will tell you that.