PART 4: MEMBER SERVICE IS A HEALTH PLAN STRATEGY
Member service is a crucial strategy for health plans. A third-party administrator (TPA) can process claims accurately but still provide a poor health plan experience.
VP of Employee Benefits · BHC Insurance · Independent Benefits Consultant
Member service is a crucial strategy for health plans. A third-party administrator (TPA) can process claims accurately but still provide a poor health plan experience. This may seem unfair, but it reflects the reality employers encounter. Employees view the health plan differently than actuaries, consultants, or claims administrators. Their experience is shaped by claim denials, missing ID cards, unverified coverage, or confusion about their financial responsibilities.
In these moments, the TPA embodies the health plan. The quality of their response can significantly impact how employees perceive the benefits, the employer, and the overall enrollment experience. Therefore, member service must not be an afterthought.
Employers should assess call-center performance, response times, escalation procedures, advocacy support, communication tools, and the TPA’s ability to clarify complex issues in simple terms. It is also essential to look beyond average call statistics. Consider what happens when an employee faces a serious diagnosis or when a hospital demands a large upfront payment. Can the member reach someone who takes ownership of their issue? Will the TPA investigate and help find solutions, rather than just explaining the claim system?
Effective member service is not about approving every claim or eliminating all frustrations; healthcare is complex, and some issues require time to resolve. The key is whether employees feel supported in navigating the process.
This is particularly vital for HR teams. Weak TPA service leads to unresolved issues reverting to HR, resulting in hours spent tracking claims, contacting vendors, explaining coverage, and managing employee frustration. A strong TPA should alleviate the administrative burden on HR, not add to it.
Employers often invest considerable time comparing provider discounts and administrative fees, which are important factors. However, the lowest-cost TPA can become costly when poor service leads to confusion, employee dissatisfaction, delayed care, and extra work for the employer. The member experience should be evaluated with the same rigor as financial performance.
In Part 5, I will summarize the series with key questions employers should consider when selecting or replacing a TPA.
Questions about this topic? I'm available for consulting engagements across Northwest Arkansas and beyond.
Sources & Further Reading
- EBRI: Workers' Views on Health Care Costs and Coverage (2024) — Employee data on health plan satisfaction, claims experience, and the relationship between member service quality and benefit value perception.
- KFF Employer Health Benefits Survey 2024 — Benchmark data on employee satisfaction with employer health plans and the factors that drive positive member experience.
- PBGH: Member Engagement and Health Plan Performance — Employer coalition research on the relationship between member service quality and total plan cost outcomes.
- DOL: ERISA Claims and Appeals Procedures — Regulatory requirements for claims processing and appeals — the compliance foundation for member service standards.
- Health Affairs: Patient Navigation and Health Outcomes — Research on how member navigation and support services affect care utilization and health outcomes for employer plan members.
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About the Author
Corry Hull, REBC®, CSFS®
VP of Employee Benefits · BHC Insurance
Corry Hull, REBC® CSFS®, is VP of Employee Benefits at BHC Insurance and the founder of Employer Benefits IQ (www.employerbenefitsiq.com). He is a Certified Health Rosetta Advisor — one of fewer than 200 nationwide — and a multi-year presenter at United Benefit Advisors (UBA) national conferences. He specializes in self-funded health plan design, PBM contract strategy, stop-loss structuring, group medical captives, and ACA/ERISA compliance for mid-market employers. His work has been recognized by Health Rosetta (Rosie Award, 2026), UBA (Producer Peak Performer, 2025–2024), and BHC Insurance (Producer of the Year, 2021–2025). His employer-education content has been referenced in BenefitsPro and cited within the Health Rosetta advisor community. All consulting and brokerage compensation is fully disclosed.