Third Party Administrator

Third Party Administrator (TPA) is an intermediary company between an insured and insurer. It is an organisation which processes claim settlement and also provide cashless facility in a cost effective, timely, fair and smooth manner. Health insurance industry in India is growing at a fast pace and hence need to be supported by a robust infrastructure. They associate with multiple insurance companies, to get critical mass from best leverage technology and deliver cost effective services to both policy holder and insurance companies.

TPAs play a major role in providing support and increasing efficiency of the industry.

Smooth Claim Settlement:

TPA streamlines the whole process of claim settlement. Besides managing customers, it is also the job of a TPA to coordinate with the hospital for the claim settlement process. In case of cashless hospitalization, they monitor and collects all the required documents from the hospital, an insured need to inform TPA about hospitalisation within 24 hours. They will take care of the cashless hospitalization. They will collect all the bills from the hospital, examine the policy terms and will pass the claim.

In the case of non-cashless claims, they will settle the amount on a reimbursement basis. All the required documents, the original need to be submitted to TPA within the due time. Generally, the claim will be passed within one month of document submission. The TPA can take a second medical opinion for complicated cases and can also investigate hospital records in case of suspicious claims.

Managing policyholder records:

Maintenance of the database of policyholders, issuing of identity cards, claim settlement and grievance redressal, all come under the responsibility of a TPA. It takes care of administration work and creates a database of all the necessary documents of all the policyholders. They issue health-card to policyholders which help in availing cashless hospitalization and also helps in disseminating all the crucial information to policyholders. Informing customers about the list of network hospitals. Besides, the TPA is responsible for making payment to the hospital. A TPA in-turn receives Reimbursement once it sends all the supporting documents for the claim, along with the bills to the insurance company.

Building network:

The TPA builds network with hospitals to get cashless services and also negotiate rates and discounts. It also takes into consideration the infrastructure and facilities of the hospital, track record, management background and IT infrastructure / computerization at the hospital to add hospitals on their network.

Maintain service centre:

The TPA maintains 24- hour customer service centre, which can be accessed from anywhere in the country and can be used for asking and solving queries where customer can speak and get information regarding hospital network, policies, eligibility for claim and status of claim benefit if reimbursement in pending.

Value-added services:

Apart from these claim process, TPA also provide various value-added services to the policy holder. Ambulance services if mentioned in the policy, guidance to the policy holders, lifestyle management and well-being programs are some of the value added services offered by TPAs.

Therefore, TPA brings improvement in delivery services, better standardization and plays crucial role in overall development of health insurance industry and its customers. 

Thank you

Regards

Author - Jagruti

Kautilya

IBS Mumbai