Description
Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care and health system expenses, among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is available to pay for the health care benefits specified in the insurance agreement.
Role of TPA
Third Party Administrator is a company that manages insurance processes usually the service part on the behalf of insurer and receives commission in return. Insurance companies outsource some aspects of insurance business to make the process hassle free and efficient. TPA’s perform these services and acts as intermediary between the insurer and the insured. TPAs were introduced by the IRDA in the year 2001. The core service of a TPA is to ensure better services to policyholders. Their basic role is to function as an intermediary between the insurer and the insured and facilitate cash less service at the time of hospitalization. A minimum capital requirement of Rs.10 million and a capping of 26% foreign equity are mandatory requirements for a TPA as spelt by the IRDA. License is usually granted for a minimum period of three years. Ideally, The TPA functions by collaborating with the hospitals in order for the patient to enjoy hospitalization services on a cashless basis TPA’s first role is to issue identity card with unique identification number and provide insured with a guidebook on claims process with a list of networked hospitals. The other functions performed by TPA are:
1. Claims Process: TPA primary role is to process claims both cashless and claim reimbursement.
CASHLESS CLAIMS- THE INSURED NEEDS TO PROVIDE THE NETWORK
HOSPITAL WITH HOSPITAL
TPA
ISSUED IDENTITY CARD OR POLICY NUMBER . AUTHORIZATION DETAILS WITH
SENDS
PRE
THE DOCTOR ’S
CERTIFICATE, TREATMENT DETAILS ETC. LEGITIMATE,
IF
FOUND THAT CLAIM IS
TPA
ISSUES LETTER AUTHORIZING HOSPITAL TO PROCEED
SPECIFYING THE MAXIMUM LIMIT OF COVER .
CLAIM REIMBURSEMENT - THE INSURED NEEDS TO CONTACT TPA AS
SOON AS POSSIBLE AND INTIMATE ABOUT THE CLAIM.
DOCUMENTS LIKE CLAIM FORM , HOSPITALIZATION DETAILS, DIAGNOSTIC TESTS , TREATMENT BILLS, POLICY DUPLICATE SHOULD BE PROVIDED TO TPA. IF FOUND LEGITIMATE, TPA WILL REIMBURSE THE CLAIM.
2. Enlist Health Care Providers: TPA also ties up with hospitals to provide more comprehensive coverage to the insured. The selection criterion depends on location, infrastructure, facilities available etc.
3. Customer Support: TPA maintains dedicated call centre to provide quick access to policyholders, respond to their queries and update about claim status. TPA’s also have websites for online assistance.
4. What are documents required in absence of cashless facility by TPA?
? ? ? ? ? ?
CLAIM FORM DULY FILLED BY CLAIMANT ORIGINAL DISCHARGE SUMMARY FROM THE HOSPITAL DOCTOR’S CONSULTATION REPORT , SPECIALIST FEES LABORATORY TESTS UNDERGONE DOCTOR ’ S AUTHORIZATION .
BY PATIENT ALONG WITH
ALL MEDICALS INVOICE ALONG WITH DOCTOR ’S PRESCRIPTION ANY OTHER DOCUMENT ,POLICY COPY IF AVAILABLE
RELATED TO HOSPITALIZATION
What if TPA rejects claim?
TPA rejects claims if it finds the claim not being genuine. Whenever TPA rejects claim, the reason for rejection is also stated. However if you feel that TPA rejection is unjustified, you can contact your insurer within few days of rejection to present your concerns Role of TPA is to coordinate with hospitals respect of treatment and also pass the bills on behalf of insurance companies. But the actual payment of claims is done by insurance company only. Introduction of TPA is great help and relief to the insurance companies. TPA performs all functions which are required in the process of a particular claim. Once policy has been issued work of TPA starts thereafter, Insurance company passes all the all records to the TPA and all further correspondence of the insured will be with TPAs and not with insurance company. TPA which are expected to provide value added services to policyholders such as medicines and supplies, arranging ambulance services, guiding and helping insured with queries, 24 hour help lines, health facilities, bed availability etc. Another general thinking was that with the arrival of TPA the insured person would be benefitted and spared from the hassles of remittance after spending in the hospital. But the general feeling amongst the insured persons, especially those who have opted for individual insurance, is that the conduct of TPA is more pro-insurance companies instead of coming to the rescue of the insured at the time of crisis
They are also potentially equipped to play a wider role in standardization of charges for various treatments and procedures, benefits management, medical management, provider network management, claim administration and maintaining a database of health insurance policies.
ASSOCIATION MEMBERS Timely financial information Accurate account statements Consistent record keeping Visibilty and access
? ? ? ?
Role of TPA
PROPERTY MANAGER Better Informed clients ? Reduced client work ? Actionable reports ? Improved Productivity ?
ASSOCATION BOARD By law Compliance Recievables Management ? Budget and Forecast ? Tax fillings ? ?
Functions of TPAs ( Cashless Claim): ? TPA ISSUES ID CARDS TO ALL THEIR POLICYHOLDERS IN ORDER TO VALIDATE THEIR IDENTITY AT THE TIME OF ADMISSION . ? IN CASE OF CLAIM , POLICYHOLDER WILL HAVE TO INFORM TPA ON THEIR 24 HR TOLL FREE LINE . ? AFTER INFORMING TPA, THE POLICYHOLDER WILL BE DIRECTED TO A HOSPITAL WHERE THE TPA HAS A TIED UP ARRANGEMENT . ? TPA PAYS FOR TREATMENT ; THEY ISSUE AUTHORIZATION LETTER TO THE HOSPITAL FOR ADMISSION OF POLICYHOLDER . ? AT THE TIME OF DISCHARGE ALL THE BILLS WILL SEND TO TPA TO ANALYZE CASE OF INSURED AT HOSPITAL . ? THEN TPA MAKES THE PAYMENT TO HOSPITAL. ? TPA SENDS ALL NECESSARY DOCUMENTS OF CLAIMS TO INSURANCE COMPANY .
?
INSURANCE COMPANY THEN REIMBURSES TPA.
With help of TPAs, insurance companies able to provide better service to their policyholders as burden of claim settlement passes on to TPA. TPA which helps insured as well as insurance companies and ensures higher efficiency in the process of claim settlement
Third party administrators are prominent players in the managed care industry and have the expertise and capability to administer all or a portion of the claims process. They are normally contracted by a health insurer or self-insuring companies to administer services, including claims administration, premium collection, enrollment and other administrative activities. A hospital or provider organization desiring to set up its own health plan will often outsource certain responsibilities to a TPA. For example, an employer may choose to help finance the health care costs of its employees by contracting with a TPA to administer many aspects of a self-funded health care plan.
doc_756700413.docx
Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care and health system expenses, among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is available to pay for the health care benefits specified in the insurance agreement.
Role of TPA
Third Party Administrator is a company that manages insurance processes usually the service part on the behalf of insurer and receives commission in return. Insurance companies outsource some aspects of insurance business to make the process hassle free and efficient. TPA’s perform these services and acts as intermediary between the insurer and the insured. TPAs were introduced by the IRDA in the year 2001. The core service of a TPA is to ensure better services to policyholders. Their basic role is to function as an intermediary between the insurer and the insured and facilitate cash less service at the time of hospitalization. A minimum capital requirement of Rs.10 million and a capping of 26% foreign equity are mandatory requirements for a TPA as spelt by the IRDA. License is usually granted for a minimum period of three years. Ideally, The TPA functions by collaborating with the hospitals in order for the patient to enjoy hospitalization services on a cashless basis TPA’s first role is to issue identity card with unique identification number and provide insured with a guidebook on claims process with a list of networked hospitals. The other functions performed by TPA are:
1. Claims Process: TPA primary role is to process claims both cashless and claim reimbursement.
CASHLESS CLAIMS- THE INSURED NEEDS TO PROVIDE THE NETWORK
HOSPITAL WITH HOSPITAL
TPA
ISSUED IDENTITY CARD OR POLICY NUMBER . AUTHORIZATION DETAILS WITH
SENDS
PRE
THE DOCTOR ’S
CERTIFICATE, TREATMENT DETAILS ETC. LEGITIMATE,
IF
FOUND THAT CLAIM IS
TPA
ISSUES LETTER AUTHORIZING HOSPITAL TO PROCEED
SPECIFYING THE MAXIMUM LIMIT OF COVER .
CLAIM REIMBURSEMENT - THE INSURED NEEDS TO CONTACT TPA AS
SOON AS POSSIBLE AND INTIMATE ABOUT THE CLAIM.
DOCUMENTS LIKE CLAIM FORM , HOSPITALIZATION DETAILS, DIAGNOSTIC TESTS , TREATMENT BILLS, POLICY DUPLICATE SHOULD BE PROVIDED TO TPA. IF FOUND LEGITIMATE, TPA WILL REIMBURSE THE CLAIM.
2. Enlist Health Care Providers: TPA also ties up with hospitals to provide more comprehensive coverage to the insured. The selection criterion depends on location, infrastructure, facilities available etc.
3. Customer Support: TPA maintains dedicated call centre to provide quick access to policyholders, respond to their queries and update about claim status. TPA’s also have websites for online assistance.
4. What are documents required in absence of cashless facility by TPA?
? ? ? ? ? ?
CLAIM FORM DULY FILLED BY CLAIMANT ORIGINAL DISCHARGE SUMMARY FROM THE HOSPITAL DOCTOR’S CONSULTATION REPORT , SPECIALIST FEES LABORATORY TESTS UNDERGONE DOCTOR ’ S AUTHORIZATION .
BY PATIENT ALONG WITH
ALL MEDICALS INVOICE ALONG WITH DOCTOR ’S PRESCRIPTION ANY OTHER DOCUMENT ,POLICY COPY IF AVAILABLE
RELATED TO HOSPITALIZATION
What if TPA rejects claim?
TPA rejects claims if it finds the claim not being genuine. Whenever TPA rejects claim, the reason for rejection is also stated. However if you feel that TPA rejection is unjustified, you can contact your insurer within few days of rejection to present your concerns Role of TPA is to coordinate with hospitals respect of treatment and also pass the bills on behalf of insurance companies. But the actual payment of claims is done by insurance company only. Introduction of TPA is great help and relief to the insurance companies. TPA performs all functions which are required in the process of a particular claim. Once policy has been issued work of TPA starts thereafter, Insurance company passes all the all records to the TPA and all further correspondence of the insured will be with TPAs and not with insurance company. TPA which are expected to provide value added services to policyholders such as medicines and supplies, arranging ambulance services, guiding and helping insured with queries, 24 hour help lines, health facilities, bed availability etc. Another general thinking was that with the arrival of TPA the insured person would be benefitted and spared from the hassles of remittance after spending in the hospital. But the general feeling amongst the insured persons, especially those who have opted for individual insurance, is that the conduct of TPA is more pro-insurance companies instead of coming to the rescue of the insured at the time of crisis
They are also potentially equipped to play a wider role in standardization of charges for various treatments and procedures, benefits management, medical management, provider network management, claim administration and maintaining a database of health insurance policies.
ASSOCIATION MEMBERS Timely financial information Accurate account statements Consistent record keeping Visibilty and access
? ? ? ?
Role of TPA
PROPERTY MANAGER Better Informed clients ? Reduced client work ? Actionable reports ? Improved Productivity ?
ASSOCATION BOARD By law Compliance Recievables Management ? Budget and Forecast ? Tax fillings ? ?
Functions of TPAs ( Cashless Claim): ? TPA ISSUES ID CARDS TO ALL THEIR POLICYHOLDERS IN ORDER TO VALIDATE THEIR IDENTITY AT THE TIME OF ADMISSION . ? IN CASE OF CLAIM , POLICYHOLDER WILL HAVE TO INFORM TPA ON THEIR 24 HR TOLL FREE LINE . ? AFTER INFORMING TPA, THE POLICYHOLDER WILL BE DIRECTED TO A HOSPITAL WHERE THE TPA HAS A TIED UP ARRANGEMENT . ? TPA PAYS FOR TREATMENT ; THEY ISSUE AUTHORIZATION LETTER TO THE HOSPITAL FOR ADMISSION OF POLICYHOLDER . ? AT THE TIME OF DISCHARGE ALL THE BILLS WILL SEND TO TPA TO ANALYZE CASE OF INSURED AT HOSPITAL . ? THEN TPA MAKES THE PAYMENT TO HOSPITAL. ? TPA SENDS ALL NECESSARY DOCUMENTS OF CLAIMS TO INSURANCE COMPANY .
?
INSURANCE COMPANY THEN REIMBURSES TPA.
With help of TPAs, insurance companies able to provide better service to their policyholders as burden of claim settlement passes on to TPA. TPA which helps insured as well as insurance companies and ensures higher efficiency in the process of claim settlement
Third party administrators are prominent players in the managed care industry and have the expertise and capability to administer all or a portion of the claims process. They are normally contracted by a health insurer or self-insuring companies to administer services, including claims administration, premium collection, enrollment and other administrative activities. A hospital or provider organization desiring to set up its own health plan will often outsource certain responsibilities to a TPA. For example, an employer may choose to help finance the health care costs of its employees by contracting with a TPA to administer many aspects of a self-funded health care plan.
doc_756700413.docx