Understanding Third-Party Administrators (TPAs) and Their Impact on Dental Billing
Insights from DeVon at D-Tech Billing and Claims, featured expert at July’s Dental Insurance Live
If you’ve ever submitted a clean claim only to be met with a puzzling denial—or seen reimbursement come back from a payer you’ve never heard of—it’s likely you were dealing with a third-party administrator. TPAs serve as intermediaries between the insurance carrier and the provider, and their role is growing.
In her highly regarded session at Dental Insurance Live, DeVon from D-Tech Billing and Claims outlined exactly how TPAs impact billing processes. Her expertise stems from years of hands-on experience navigating claim submission pathways, payer networks, and portal logic—often where things go wrong. For billing professionals and dental practice leaders alike, understanding TPAs is no longer optional. It’s essential.
What Are TPAs—and Why Do They Matter?
Third-party administrators manage a range of services for self-funded employer groups, unions, and some commercial carriers. These services may include:
- Claims processing
- Provider network access
- Eligibility verification
- Fee schedule administration
They don’t underwrite risk, but they do hold significant power in how and when providers are paid. According to DeVon, failing to identify the presence of a TPA early in the billing process is one of the most common sources of denials and delayed payments.
“Aetna may be the name on the card, but if UMR is the TPA, everything from portal access to claim logic changes. If your team isn’t catching that upfront, you’re going to see a hit to your collections,” DeVon explained during her session.
The Reimbursement Gap: Hidden Fee Compression
One of the more costly impacts of TPAs is that they often introduce fee schedule compression without a provider realizing it. Dental practices may be billing based on what they believe to be their contracted rate—only to receive payment at a significantly reduced amount due to a TPA’s internal fee structure.
To address this, DeVon recommends that practices:
- Perform segmented reimbursement audits by payer and group
- Cross-reference EOBs with TPAs to identify trends in reductions
- Document known TPA relationships (e.g., CoreSource, UMR, BAS) for each major carrier
Without this clarity, even well-run billing departments can find themselves constantly chasing revenue they never agreed to discount.
Updating Verification Protocols
Another point DeVon emphasized is the importance of upgrading insurance verification workflows to catch TPAs early. A patient’s card may show Cigna or Aetna, but the plan may be fully administered through a third-party system.
Best practices include:
- Asking specifically, “Is this plan administered by a TPA?”
- Capturing both the carrier and the TPA name in the patient record
- Verifying portal access and claim submission routing before treatment
Practices that don’t ask these questions may experience delayed eligibility confirmation or misfiled claims.
Tech and Workflow Considerations
DeVon noted that practice management systems and clearinghouses often struggle with TPA routing logic. Her recommendation:
- Maintain internal TPA lists with associated payer IDs
- Use clearinghouses that allow for payer-level filtering
- Create step-by-step TPA submission guides for the billing team
This internal knowledge base not only speeds up claim filing, it reduces training time for new team members and safeguards collections when staff transitions occur.
From Confusion to Control: Making TPAs Work for You
Rather than seeing TPAs as obstacles, DeVon urged attendees to shift their perspective and use them as levers for better control. If your practice is out-of-network with a TPA, it may open the door for higher fee collection—with proper patient communication. If you’re in-network, understanding the TPA relationship can help you renegotiate or reallocate payer mix more strategically.
“You don’t have to be powerless,” DeVon said. “You just need to know who you’re actually working with.”
Conclusion
Third-party administrators introduce complexity, but also opportunity. With expert guidance like that from DeVon and her team at D-Tech Billing and Claims, practices can move from confusion to clarity—and from lost revenue to optimized performance.
By taking a proactive approach to verification, claim routing, and fee analysis, your billing department can stay ahead of TPA challenges and build a more predictable, efficient revenue cycle.
About the Expert
DeVon is the founder of D-Tech Billing and Claims, a dental billing firm specializing in claim navigation, insurance policy compliance, and high-performance revenue cycle strategy. She was a featured speaker at July’s Dental Insurance Live, where she educated hundreds of dental professionals on the hidden mechanics of third-party administrators and fee optimization.