Here's a question I have heard more than once: What is a practical, speedy way to assess whether a TPA (third-party administrator) is truly independent and willing to protect the plan's interests, this plan sponsor's interests, versus being captive to, for example, network contracts or carrier relationships or other conflicts of interest? What's an easy tell that can give you an answer fast?
For a full transcript of this episode, click here.
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After being posed this question, I knew the perfect person to call to get an answer; and that perfect person would be Kimberly Carleson from US Beacon, the CEO of US Beacon.
What You'll Learn
✅ The one question that quickly exposes whether a TPA is truly independent
✅ Why a TPA answering "We have network contracts that restrict that" is a red flag—it means they are working for the network, not the plan
✅ What a TPA should hand over without hesitation when a plan sponsor asks for an independent claims audit
✅ How blocking language in TPA and network contracts—restrictions on accessing data or contacting providers—can stop a plan from independently reviewing its own claims and payments
✅ How an "independent" TPA can still be beholden to a network, renting that network and acting the same way any BUCA would
✅ Why labels like "transparent" and "independent" aren't proof, and why due diligence matters: talk is cheap
Why This Matters
Plan sponsors who go self-funded want to do their own thing and bring in their own vendors, not end up "self-funded in name only," as Jonathan Baran calls it. But irrespective of what a partner calls itself, it's still really important to validate what you hear. A TPA's willingness to let you bring in your own auditor—with access to the data and no blocking language in its network contracts—is a fast way to find out whether it works for the plan or for the network. And as Kimberly says, if you can't bring in who you want to bring in, there's something they don't want you to see.
And with that, here is my Ask Me Anything with Kimberly Carleson.
Also mentioned in this episode are US Beacon, Claire Brockbank, Jonathan Baran, and Arielle Bose.
For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here.
You can learn more at us-beacon.com and by following Kimberly on LinkedIn.
Kimberly Carleson is a nationally respected healthcare executive and patient advocate with more than 15 years of experience serving patients, self-funded health plans, state governments, public entities, small businesses, and Fortune 500 companies in the areas of reimbursement integrity, regulatory compliance, and fiduciary governance.
As CEO of US Beacon, Kimberly leads one of the nation's most established independent medical and pharmacy claims compliance and integrity review firms, supporting self-funded health plans, municipalities, and large employers. Her work focuses on identifying systemic overbilling, coding inaccuracies, and contractual noncompliance, delivering substantial, defensible savings while strengthening oversight and accountability.
She has served as a panelist for ERIC (The ERISA Industry Committee) and the National Auditors Association, and her work has been referenced in federal policy discussions related to healthcare oversight and fiduciary accountability.
00:00 Introduction to this episode.
01:19 The conversation with Kimberly Carleson.
01:50 EP518 with Claire Brockbank.
02:24 The one question to tell if a TPA is independent.
03:30 Breaking down the thought process behind this question.
05:59 How an independent TPA can still be beholden to a network.
06:48 Why it's so important to do due diligence.
Recent past interviews:
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NOTE This file was generated by Descript
00:00:00 --> 00:00:03 Here's a question I have heard more than once.
00:00:03 --> 00:00:10 What is a practical, speedy way to assess whether a TPA, third-party
00:00:10 --> 00:00:19 administrator, is truly independent and willing to protect the plan's interests,
00:00:19 --> 00:00:25 this plan sponsor's interests versus being captive to, for example, network
00:00:25 --> 00:00:28 contracts or carrier relationships or other conflicts of interest?
00:00:29 --> 00:00:34 What's an easy tell that can give you an answer fast?
00:00:34 --> 00:00:38 After being posed this question, I knew the perfect person to call
00:00:38 --> 00:00:42 to get an answer, and that perfect person would be Kimberly Carleson
00:00:42 --> 00:00:45 from US Beacon, the CEO of US Beacon.
00:00:46 --> 00:00:47 My name is Stacey Richter.
00:00:47 --> 00:00:49 This is Relentless Health Value.
00:00:49 --> 00:00:51 Thank you so much for being here.
00:00:51 --> 00:01:00 Thank you also so much to those of you who have financially supported the podcast
00:01:00 --> 00:01:04 and to everybody who has taken it upon yourselves to leave a tip in the tip jar
00:01:04 --> 00:01:07 or who has supported us in other ways.
00:01:07 --> 00:01:11 If you're looking for something to do right now which might be of help, I
00:01:11 --> 00:01:16 would ask you to please go over to Apple Podcasts or Spotify and leave a review.
00:01:16 --> 00:01:19 It definitely helps other listeners find the show.
00:01:19 --> 00:01:24 And with that, here is my Ask Me Anything with Kimberly Carleson.
00:01:25 --> 00:01:27 Kimberly Carleson, welcome to Relentless Health Value.
00:01:27 --> 00:01:29 Thank you for having me, Stacey.
00:01:29 --> 00:01:30 It's a pleasure always.
00:01:31 --> 00:01:35 Today we have an Ask Me Anything, and I'm just gonna paraphrase.
00:01:35 --> 00:01:44 What is a practical, speedy way to assess whether a TPA I guess an ASO, but the
00:01:44 --> 00:01:50 question I think is more specifically about a third-party administrator, a TPA.
00:01:51 --> 00:01:53 And for more on this, go back and listen to the episode with Claire
00:01:53 --> 00:01:56 Brockbank that talks about the difference between a TPA and an ASO.
00:01:56 --> 00:02:03 But let's talk about a TPA, whether they are truly independent and willing to
00:02:03 --> 00:02:09 protect a plan's interests, like whether interests are aligned here, versus whether
00:02:09 --> 00:02:15 the TPA, the third-party administrator, is kind of maybe to a, maybe too great
00:02:15 --> 00:02:20 of a degree being sort of captive to the network contracts or carrier
00:02:20 --> 00:02:23 relationships that that TPA may have.
00:02:24 --> 00:02:25 Let's just start at the top here.
00:02:25 --> 00:02:30 Is there one kind of like one question to rule them all, one tell to rule them all?
00:02:30 --> 00:02:36 Like, how do you, how would you assess whether it's, this TPA is, like,
00:02:36 --> 00:02:41 independent, or whether the TPA, mm, may have, may find themselves
00:02:41 --> 00:02:44 running up against other interests?
00:02:45 --> 00:02:47 A few misaligned incentives maybe.
00:02:47 --> 00:02:52 I think the one way to tell is you'd ask them one question, and you say,
00:02:52 --> 00:02:57 "Can we have someone come in and independently review our claims?"
00:02:58 --> 00:03:01 If they say, "We have network contracts that restrict that," then
00:03:01 --> 00:03:05 you know that is a red flag, and they are not truly independent.
00:03:05 --> 00:03:07 They are working for the network, not the plan.
00:03:08 --> 00:03:12 So the one way to tell is, are they gonna allow independents
00:03:12 --> 00:03:14 on review for their claims?
00:03:15 --> 00:03:17 Are they gonna allow you all the data?
00:03:17 --> 00:03:22 Are they gonna allow you your billed, your paid, and your allowed charges?
00:03:23 --> 00:03:25 Are they gonna allow you to see all the claims data?
00:03:25 --> 00:03:28 Those are things that if they have any hesitation on, you know
00:03:28 --> 00:03:29 they are not truly independent.
00:03:30 --> 00:03:32 Okay, so let's parse this down.
00:03:32 --> 00:03:37 It sounds like your big kahuna question is, "Will you allow someone to come in
00:03:37 --> 00:03:43 and audit the claims that you're paying on my plan's behalf? Will you let someone
00:03:43 --> 00:03:45 come in and take a look at these claims?"
00:03:46 --> 00:03:53 If they say "Yes", if they say, "Yes, sure," most likely it's like,
00:03:53 --> 00:03:55 No further questions, Your Honor.
00:03:55 --> 00:03:57 You know what I mean?
00:03:57 --> 00:03:57 Sealed and done.
00:03:58 --> 00:04:00 It's probably, if there's no hesitation there.
00:04:00 --> 00:04:05 Yeah, I can see why you pick that as a big tell, because there's a lot of
00:04:05 --> 00:04:09 things that are sort of implied if they're okay with an independent audit.
00:04:09 --> 00:04:13 One of them is, as you mentioned, access to data.
00:04:13 --> 00:04:17 Because you can't do an audit unless you have access to the data.
00:04:17 --> 00:04:25 But the other thing that I'm hearing as part of this is that the TPA would've had
00:04:25 --> 00:04:29 to have ensured that there's no blocking language in the contracts, which is
00:04:29 --> 00:04:30 another thing that we hear a lot about.
00:04:31 --> 00:04:32 That's right.
00:04:32 --> 00:04:37 So a lot of times it will state that, you are not allowed to access the data, you're
00:04:37 --> 00:04:40 not allowed to contact their providers.
00:04:40 --> 00:04:43 They have a lot of things in the contract that don't allow the plan
00:04:43 --> 00:04:45 to independently review claims.
00:04:45 --> 00:04:50 So that is one of the big things that you wanna make sure that your contracts do not
00:04:50 --> 00:04:55 prohibit you from anything of reviewing independently on your data and your
00:04:55 --> 00:04:57 claims and your payments that you make.
00:04:58 --> 00:04:59 Yeah.
00:04:59 --> 00:05:03 And as we're talking about, you know, like, the, the question that was asked
00:05:03 --> 00:05:07 here is, you know, how do you make sure that a TPA is truly independent
00:05:07 --> 00:05:14 and not beholden to a network that they may… You know, like, the, the
00:05:14 --> 00:05:17 thing with a TPA is that you're kind of bringing your own network, or at
00:05:17 --> 00:05:19 least that's the idea there, right?
00:05:19 --> 00:05:21 Like, you have the third-party administrator, and then the
00:05:21 --> 00:05:23 network is kind of separate.
00:05:23 --> 00:05:27 But if the TPA is working so closely with these networks that they have
00:05:27 --> 00:05:32 contracts that they're beholden to the network such that the contractual
00:05:32 --> 00:05:37 language prohibits certain things from happening, then, you know, I can
00:05:37 --> 00:05:39 definitely see what you're saying.
00:05:39 --> 00:05:44 That's a really good tell that the TPA ha- is, is, may not be quite as
00:05:44 --> 00:05:48 independent as you may like as a plan sponsor who's trying to figure out how
00:05:48 --> 00:05:50 to create your own self-funded plan.
00:05:51 --> 00:05:52 That's right.
00:05:52 --> 00:05:55 So when I heard of independent TPAs, I thought, Oh, great.
00:05:55 --> 00:05:58 This is, we're gonna be a, be able to be away from the BUCA.
00:05:58 --> 00:06:00 We're not gonna have these restrictions.
00:06:00 --> 00:06:05 But really it's just sometimes a TPA that's renting their network and still the
00:06:05 --> 00:06:07 same actions as what any BUCA would be.
00:06:07 --> 00:06:10 So they're beholden to that network.
00:06:10 --> 00:06:15 You wanna make sure if that TPA does not work for you, it's beholden to the
00:06:15 --> 00:06:19 network and it's still handcuffed, so you've gotta find one that is truly
00:06:19 --> 00:06:22 independent and is able to fight for you.
00:06:23 --> 00:06:23 Yeah.
00:06:23 --> 00:06:27 I, what I'm thinking about here, Kimberly, and this is a really interesting
00:06:27 --> 00:06:32 conversation, but it just underlines for me the idea that irrespective
00:06:32 --> 00:06:37 of what someone calls themselves, like, there's plenty of partners,
00:06:37 --> 00:06:44 vendors, transparent dot dot dots out there and it sorta doesn't matter in
00:06:44 --> 00:06:47 a way how they classify themselves.
00:06:48 --> 00:06:55 It's still really important to do the due diligence here and validate what
00:06:55 --> 00:07:00 is heard, 'cause talk is cheap, and there's a really big difference between-
00:07:00 --> 00:07:05 People use a lot, right, people use a lot of words to make themselves
00:07:05 --> 00:07:10 sound transparent, independent, that sound really good and catchy and make
00:07:10 --> 00:07:13 you think that you are gonna have control of your plan when in reality,
00:07:13 --> 00:07:15 those words are used to pull you in.
00:07:16 --> 00:07:19 And they're tricky, so you always wanna follow through.
00:07:19 --> 00:07:22 Just kind of in summary, I think you gave a really practical answer
00:07:22 --> 00:07:26 here, Kimberly, that I think a lot of people are gonna … It's kind of a,
00:07:27 --> 00:07:31 yeah, like a big kahuna of a a tell.
00:07:32 --> 00:07:32 If
00:07:32 --> 00:07:37 you wanna figure out if a TPA is truly independent, and you simply
00:07:37 --> 00:07:42 ask, "Can I have an independent claims audit? Can I bring in my own
00:07:42 --> 00:07:46 people to audit, because I'm trying to make my own self-funded plan?"
00:07:46 --> 00:07:49 Like, I've heard Jonathan Baran calling it self-funded in name only.
00:07:50 --> 00:07:50 You know what I mean?
00:07:50 --> 00:07:53 Like, I really wanna make my own self-funded plan here.
00:07:53 --> 00:07:54 That's the whole reason I'm going self-funded.
00:07:54 --> 00:07:55 I wanna do my own thing.
00:07:55 --> 00:07:56 I wanna bring in my own vendors.
00:07:57 --> 00:08:00 And if you say to that TPA, "Well, great, can I bring in my own auditor?"
00:08:00 --> 00:08:05 And they're like, "Nope," well, that's a pretty good sign to dig in further.
00:08:05 --> 00:08:06 That's the red flag.
00:08:06 --> 00:08:07 That's the red flag right there.
00:08:07 --> 00:08:10 If they don't want… There's something they don't want you to see if you can't
00:08:10 --> 00:08:12 bring in who you want to bring in.
00:08:13 --> 00:08:15 Thank you so much, Kimberly Carleson, for answering this question and being
00:08:15 --> 00:08:17 on Relentless Health Value today.
00:08:17 --> 00:08:18 Thank you, Stacey.
00:08:18 --> 00:08:19 I appreciate it.
00:08:20 --> 00:08:21 Hi, this is Arielle Bose.
00:08:22 --> 00:08:26 I've reflected on this a great deal and honestly feel that listening to Relentless
00:08:26 --> 00:08:31 Health Value has given me more actionable insight than I could ever hope to receive
00:08:31 --> 00:08:36 from another graduate degree, and it costs me absolutely nothing to listen and learn.
00:08:37 --> 00:08:40 If you want career growth and healthcare or insurance, this is
00:08:40 --> 00:08:42 the pod you need to be listening to.
00:08:42 --> 00:08:45 I highly recommend signing up for the weekly newsletter.
00:08:46 --> 00:08:48 It's a great resource because it includes all of the links
00:08:48 --> 00:08:52 mentioned in the show, plus a full transcription of Stacey's intro.