Transparency isn’t just a mandate — it’s an opportunity

The question is no longer “Did you comply?” It’s “Are you activating the value of the data you already have access to?”

Why most TPAs struggle to use transparency in coverage data effectively

According to CMS, all non-grandfathered health plans must publish pricing information for covered services, including in-network rates and out-of-network allowed amounts. That’s the letter of the law. But what about the spirit?

Most TPAs have technically complied. Tools have been developed and data is available; but execution has fallen short—and member adoption remains dismal. Why? Because we haven’t made it easy for members to recognize they have choices or to act on them with confidence.

In most cases, transparency is still operating on the sidelines. The tools are clunky, hard to find, and often require members to input exact CPT codes or log into a third-party platform they’ve never heard of. Even when pricing data is accurate, it’s disconnected from where care decisions happen, leaving members unaware, overwhelmed, or simply too late to use it.

Even care navigation teams struggle to access real-time cost insights. Incentives that promote smarter behavior aren’t front and center. And members — through no fault of their own — either don’t know the tools exist or don’t understand why they should care.

The result? We’ve buried a new key lever for cost containment beneath layers of friction and fine print.

Think about how absurd this is: Being a savvy health care shopper today means reading a 50-page plan document, understanding thousands of procedure codes, and somehow identifying a cost-effective facility — often with no up-front estimate, no central directory, and no clear reward for choosing wisely.

Until transparency is effortless — until it’s just there in front of the member at the exact moment they need it — we won’t move the needle. And that’s not just a missed opportunity from a compliance perspective. It’s a missed opportunity to reduce costs, improve outcomes, and make health care work better for everyone involved. For TPAs, this isn’t just a member experience issue — it’s a competitive one.

What TiC activation looks like in practice

For third-party administrators — especially those supporting self-funded or mid-market employers — the stakes are rising. Margin pressure is intensifying. Employers expect more than claim processing, check runs and basic call center support. And a new wave of competitors is entering the space with AI tools, integrated guidance, and member-first digital experiences.

But this shift also opens the door to competitive advantage.

Here’s what activation looks like when it’s done right:

Member-driven plan savings, enabled by AI
Today’s cost-containment strategies are often labor-intensive and reactive, driven by teams of people trying to intercept care decisions that increase costs for both members and the plan. But there’s a smarter path forward. When members are equipped with the right information at the right moment, savings become proactive and scalable. Activation means using AI to deliver real-time, personalized support, automatically surfacing high-value options without requiring members to be benefit experts.

AI agents can monitor key triggers, like early claims activity or prior authorization requests, that often signal high-cost services ahead. They proactively engage members, presenting alternative options and helping them understand their choices. Instead of requiring members to search for procedure codes or navigate clunky third-party portals, guidance is delivered seamlessly through natural conversations via voice, chat, or app, making high-value decisions easier and more intuitive.

Empowering navigation teams with pricing insights
Even the best AI tools can’t replace the value of human guidance, especially in complex or high-touch scenarios. But many navigation teams are still working with fragmented systems, relying on internal cheat sheets and piecing together strategies based on the limitations of each tool. It’s inefficient and often leaves savings untapped.

With the right technology, those same teams can ask AI for answers and receive clear, actionable information in real time, just as members would. This simplifies their workflow and allows them to support more members with greater speed and accuracy.

Today, resource constraints often limit navigation efforts to high-cost, high-utilizer cases. But AI expands that reach, uncovering savings opportunities across the broader population. The future of health care guidance isn’t one or the other, it’s a coordinated model where AI and human advocates work in tandem to improve both service and savings.

Smarter plan design and incentives
When employers and consultants can clearly see cost variation across services and providers, they can move beyond reimbursement and start designing benefits that actually influence behavior. You’ve heard of the carrot and the stick: For years, the industry has leaned on the stick, penalizing members through steep out-of-network deductibles and out-of-pocket maximums. Activated TiC data makes it possible to lead with the carrot.

Plans can now reward smart buying decisions by putting money back in members’ pockets when they choose high-quality, lower-cost care. This might include incentives like cash rewards, premium reductions, or HSA contributions — all tied to engagement with cost transparency tools. The more members engage, the more they save, and the more sustainable the plan becomes.

When transparency data informs benefit design, the plan stops being a blunt instrument and starts becoming a strategic lever for long-term savings and member satisfaction.

Why activation is the competitive edge

So what does doing what’s possible actually look like?

• A member asks a health care AI assistant a benefits question about an upcoming high-cost procedure. Instead of a generic answer — or a referral to a 50-page plan document — they receive a clear, personalized response. The assistant explains that costs for the same procedure can vary dramatically depending on location and presents several high-quality, lower-cost options to consider. No CPT codes, no manual searching, just transparent guidance delivered in plain language.

• An employer implements a benefits plan built around transparency and smart incentives, resulting in significant cost savings for the plan and HSA balances so robust that half of employees pay nothing out of pocket for their care.

• A TPA adopts technology that transforms its sunk TiC compliance costs into a strategic advantage, delivering more value to members and employers while elevating the overall healthcare experience.

Today, TiC activation isn’t a buzzword; it’s a strategy. Compliance may satisfy the letter of the law, but it won’t deliver the outcomes employers and members are looking for.

TiC is not going anywhere. As networks are required to publish actual pricing, that data becomes more powerful and more public. Members begin expecting tools and services that help them navigate and save. Employers start demanding partners who can turn data into results. Regulators continue raising the bar on what compliance truly means.

The TPAs that succeed in this environment won’t be the ones playing catch-up. They’ll be the ones who already made activation part of their DNA.

You can either do what’s required—or what’s possible.

One meets the moment. The other moves the market.

Ben Callaghan is chief experience officer of Empara, a developer of technology focused on making healthcare accessible, affordable and seamless. Empara is part of the Goodroot community of companies.