With the growth of private voluntary insurance in the unregulated
healthcare market, costs of healthcare are likely to go up. Managed
care organizations in many developed countries play an important
role in containing costs. In India, The Insurance Regulatory and
Development Authority (IRDA) has paved the way for insurance
intermediaries such as third party administrators (TPAs), who are
expected to play a pivotal role in setting up managed care systems.
TPAs have been set up to ensure better services to policyholders and
to mitigate some of the negative consequences of private health
insurance.
TPA (Health Insurance) is a service provider aiming at the
provision of cost efficient and effective administrative services
(Policyholder Assistance, Cashless Provider Network Access and
Claims adjudication) on behalf of an Insurer to the Policyholder
Health Insurance is defined as Insurance against financial losses
resulting from sickness or accidental bodily injury. Protection
that provides payment of benefits for covered sickness or injury.
Included under this heading are various types of insurance such as
accident insurance, disability income insurance, medical expense
insurance, and accidental death and dismemberment insurance.
A TPA is a person or organization that processes claims and may
perform other administrative services in accordance with a service
contract. A firm, which provides administrative services for
employers and other associations having group insurance policies.
The TPA in addition to being the liaison between the employer and
the insurer is also involved with certifying eligibility,
preparing reports required by the state and processing claims.
TPA's are being used more and more with the increase in employer
self-funded plans. Third Party Administrators (TPAs) are in the
business of processing medical claims.
TPAs - Filling The
Need Gap
Access
-
Channelising policyholders to the
qualified provider for appropriate care. Cashless access -
Facilitating policyholders to network providers.
Quality
-
Proper diagnosis and effective
treatment.
Cost
-
Negotiated rates with providers,
often discounted.
TPA Services
Benefit Management
-
Help in designing customised health plans both
for Groups/Corporate and Insurers
Contracting with providers in terms of
discounts, quality, cashless facility, utilization review (very
preliminary)
Claims Adjudication
-
Documentation, eligibility, coverage, settlement
process
Information and Data
Management
-
Regular reporting to Insurers. Data analysis
for product innovation and pricing.
TPAs organize healthcare providers by establishing networks with
hospitals, general practitioners, diagnostic centers, pharmacies,
dental clinics, physiotherapy clinics, etc.They sign a memorandum of
understanding with insurance companies according to Which they
inform policyholders about the network of healthcare delivery
facilities and various systems and processes for settling claims.
Policyholders are enrolled and registered with TPAs to avail of
these services and in the event of hospitalization, health
facilities are expected to inform the TPAs. The medical referee of
TPA examines the admissibility of the case and accordingly informs
the healthcare facility to proceed with the treatment. The agreement
between TPAs and healthcare facilities provides for monitoring and
collection of documents and bills pertaining to the treatment.
Documents are audited and after processing sent to the insurance
company for reimbursement. TPAs have the responsibility of managing
claims and getting reimbursements from the insurance company and
paying the healthcare provider.
Ex
servicemen are required to indicate in writing at the time of
admission the additional facilities they would like to avail.
Necessary payments for these including food charges will have to
be paid in cash, on admission, in advance.
