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Reliable Group

For health-plan third-party administrators

Pend backlogs, missed guarantees and retro terms caught late.

An AI operating partner that measures one claims, eligibility or stop-loss department, then builds and runs the fix.

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Table titled where margin and risk sit, comparing today with once rebuilt. Renewal turnaround: repeat pends worked one at a time, then repeat pend reasons cleared by rule. Performance guarantees: turnaround known after the quarter closes, then pend aging watched against each guarantee. Cost of a new group: file layout and build keyed by hand, then layout mapped once and AI drafting the build. Retro terms: found after claims pay, sometimes by the client auditor, then matched to paid claims with refunds drafted. Stop-loss notices: claimants and filing dates in spreadsheets, then thresholds and dates tracked and requests assembled. Dispute deadlines: notices dated in an inbox, then each tracked to its deadline.
What we rebuild in a TPA. A pattern, not a client result.

Where the hours go

  • Turnaround slips every renewal season.

    Eligibility, COB and repricing pends age against guarantees. Scripts clear repeat reasons; examiners keep plan calls.

  • New groups load by hand, file by file.

    Each group's 834 has its own layout and load errors. Scripts map each layout once and clear repeat errors.

  • Stop-loss notices run on spreadsheets.

    A missed contract deadline can cost the reimbursement. Scripts track thresholds and assemble requests.

  • Retro terms found by the client's auditor.

    They reopen paid claims, and the plan sponsor's auditor finds them first. Scripts match terms to claims; staff approve AI-drafted refunds.

  • Dispute deadlines tracked in an inbox.

    As of 2026, each No Surprises Act open negotiation notice starts a federal clock. Automation dates it; staff review AI-assembled QPA support.

  • Status calls pull staff off claims work.

    Providers and members call for status; appeals arrive by mail and fax. AI answers status from claims data and routes dated appeals.

Before and after titled why cost to serve climbs with every group. Before: twelve gray blocks, each a way one group differs, such as its own file layout, census spreadsheet, plan document, benefit build, eligibility rules, network rental, PBM carve-out, stop-loss contract and retro window. After: layouts mapped once and loaded by rule, repeat pend reasons scripted, and an examiner deciding what plans leave open.

What we do, and what we leave alone

Every new group is another plan your examiners must learn

Each self-funded or level-funded group brings its own plan document, feeds and stop-loss contract. We script pend reasons and file loads, configured and logged per group. AI drafts build worksheets; analysts sign off test claims.

  • We match retro terms to claims
  • Examiners keep plan judgment calls
  • UM vendor keeps medical necessity
  • Fiduciary decides ERISA appeals

Medicare distribution, anonymized

Healthcare services

Commissions, HR and onboarding rebuilt while the business grew

A field marketing organization placing Medicare plans for 225,000+ lives through roughly 1,500 agents. Reliable Group rebuilt commissions, HR and onboarding around automation and AI, and gave agents a voice assistant for plan comparison and compliance. Sales capacity held and the business grew through the year, while the corporate team went from about 450 to under 200.

Grew, capacity held

One year: the business grew and sales capacity held. The corporate team went from about 450 to under 200.

anonymized realized

This case is from Medicare distribution. We have not published a TPA engagement yet.

  • Growth and sales capacityanonymized realized

What transfers: Per-account rules, reconciliation and onboarding rebuilt with automation first and people on exceptions, the same pattern as group loads and pend reasons.

See the measured results

Questions TPAs ask

  • That is the reason for it. Most differences are 834 layout, census columns and benefit build, which are rules we configure group by group. Carve-outs, custom accumulators and anything the plan document leaves open are listed by group, and an examiner keeps them.

  • No. We build around it, on its files, exports and interfaces rather than screen-clicking bots that break on upgrades. The work we remove sits between that system and group files, repricing returns, carrier EOBs, stop-loss portals and the mailroom. We run what we build.

  • We sign a subcontractor business associate agreement before any data is touched. PHI stays inside your systems, accessed by named people under your group separation controls. Groups whose contracts bar access from outside the US stay with your US staff; we confirm each in discovery.

  • With the administrative part: tracking claimants against the specific deductible, drafting the threshold and trigger diagnosis notices the contract requires, and assembling claim detail for reimbursement requests. Your team approves and sends each. Contract basis, lasers and the carrier relationship stay with you.

  • We date-stamp ERISA plan claims and appeals, flag any near a limit and route appeals to the named fiduciary. Group health plan gag clause attestations are due to CMS by December 31 each year; we prepare each for your sign-off. The plan keeps the obligation.

  • A fixed fee for one department, usually claims or eligibility, over six to eight weeks. You get a workflow map and a fixed-price proposal for the first build, valued in examiner hours. Then build it yourself, have us build and run it, or stop.

Sources for the rules and deadlines on this pagechecked November 1, 2026

Rules change and vary by program, state and contract. Your compliance team confirms what applies to you.

How we handle regulated data

Design posture, not certification

Request documentation
BAA
Where a department handles protected health information, we execute a business associate agreement before Trace is installed or any data is accessed.
HIPAA
We execute a Business Associate Agreement before any engagement that touches PHI, and PHI is accessed only inside client-controlled systems by named individuals. Our first healthcare engagement under BAA is in progress.
Posture
Ready and aligned describe design posture, not certification. Reliable Group does not currently hold SOC 2 or ISO 27001 certification; our teams operate inside client-certified environments under client controls.
Notice
We deploy Trace only after your organization has given team members the written notice required in your state; we provide the notice template.

Your client-specific workflows, data and documentation are yours. Trace is Reliable Group software, licensed under the engagement; third-party tools keep their own license terms.

Last reviewed October 2026

Next step

Stop guessing how your operation works.

Tell us which department eats the most hours. We will say candidly whether measuring it is worth it.

Talk to usHow we start