Third Party Administrator – Beyond Claims Processing, Part 2

Part 1 of this post detailed how the third party administrator functions for an organization that is considering self-funding as an option for its employee benefit plans.

Once an organization has chosen to self-fund its employee benefit plan, the third party administrator roles may include:

  • Consultation: The third party administrator will assist the organization in developing an employee benefit plan, or plans, that aligns with the goals of the organization.
  • Medical Management: The most effective third party administrator will provide a variety of medical management strategies that can be integrated to reduce health care expenses. Case Management, Utilization Management and Utilization Review, and Medical Review are examples of cost-effective medical management services that usually occur within effective medical management strategies.
  • Plan Administration: The third party administrator should not only assist the employer in developing a plan to fit its needs, but it should also manage the plan.
  • Cost Containment: The third party administrator should analyze claims to identify any opportunity to reduce health care expenses. This analysis may produce opportunities to renegotiate charges and identify any duplicative or unnecessary codes. In addition , the incorporation of wellness and disease management programs is an aspect of cost containment that the third party administrator could manage.
  • Network Management: The third party administrator should negotiate and maintain provider contracts and develop a robust in-network provider base. The most experienced third party administrator will have a proprietary network that the organization can access.
  • Claims Processing: The third party administrator will adjudicate and pay qualified claims.
  • Customer Service: The third party administrator should have representatives trained on the specific details of the individual plan available to address all member questions and concerns.
  • Improving Consumerism: The third party administrator provides web access and tools to make sure the employee is current on information and resources to help navigate the health care delivery system.
  • For more information on the roles of a third party administrator please contact POMCO Group at 800.934.2459 or visit