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Role of Third Party Administrator (TPA) in Health Insurance

third party health insurance

Introduction of a (Third Party Administrator) TPA is beneficial to both the health insurance companies and the insured members. The major duty of the third party in health insurance is to provide seamless services to the policyholders. TPAs work as mediators between the insurance company and the insured members for cashless claim settlement.

TPA is basically an organization or a company that is licensed to process insurance claims in addition to settling cashless claims as an outsourcing entity for the insurer.

Regulations of IRDA for TPA –

  • There should be an in-house team of doctors who are registered with the medical council of India, Insurance advisors, hospital supervisors, legal experts and IT professionals.
  • The team should align the communications with the customers to ensure the authenticity of the claims and that only relevant medical are reimbursed.
  • The insurance company pays a percentage of the insurance premium to the TPA to ensure a smooth process.

How do TPAs help in claiming health insurance?

It provides round-the-clock redressal to customer grievances and queries and reduces the administration cost for the insurance provider. TPA is, basically, a single point contact for the policyholder, insurance provider, insurance broker etc. for processing the insurance claim.

Major Benefits of TPA

  • Expeditious and seamless claim settlement
  • Provision of cashless services at ease
  • Reduction in the overhead costs
  • Easy access to highly-proficient claim supervisors
  • Improved control over claims outcomes
  • Nurturing the relationship with the customers
  • Maintaining the brand reputation in the market
  • Elimination of fraudulent acts by private insurers

Role of TPA in health insurance

As soon a health insurance policy is issued, the role of the TPA starts right from there. Elucidated below are some of the major roles of TPAs in health insurance industry.

  • Efficiently Manage the Record of the Customers– When your purchase a health insurance policy, the records of the policyholder and the insured members are shared with the TPA or Third-Party administrator. From that moment on, it is TPA’s responsibility to manage the customer’s mediclaim and establish a smooth relationship.

This includes safeguarding the policyholders’ database, claim settlement, addressing insurance-related queries and issuing identity cards to the customers.

Additionally, payment to the network hospitals is also made by the TPA. Third Party Administrator receives the claim amount from the insurer once the policyholder submits all the supporting documents and bills to the insurer.

  • 24-Hours Customer Redressal System – The customers can resolve their confusion regarding the eligibility criteria, network hospitals, and claim settlement. One can coordinate for cashless claim settlement if the treatment is undertaken at a network hospital. If the treatment was availed at a non-network hospital, then one needs to ask for the compensation of the hospitalization expenses.
  • Associating with the Network Hospitals- For cashless claim settlement, the TPA determines the hospitals which are to be listed for cashless hospitalization. While doing so, TPA takes into consideration the hospital records, infrastructure, medical facilities, reputation in the market and other relevant details to ensure the best treatment for the insured members.
  • Claim Settlement – TPA coordinates with both the hospital and the customer for the claim settlement process.

The bills of the treatment have to be shared with the TPA. Thereon, the TPA will start the verification in terms of the hospitalization expenses, hospital records, seek medical opinion (if required) and validate the claim once satisfied. If any loophole is found, the bills may have to be evaluated again.

  • Additional Services – Some TPAs provide additional services like lifestyle management programs, weight management programs, or even suggest a doctor or specialist for a particular medical condition.

Advantages of TPA in health insurance to the policyholders –

  • TPA is one point of contact for customers and all the customer records are maintained by them
  • For cashless claim settlement, negotiation, and reimbursement, the customer can seek guidance from the TPA
  • 24-hour helpline number to address health-insurance-related queries from anywhere around the country
  • Dedicated team of doctors to determine if the coverage should be provided for a particular disease or not

Advantages of TPA in Health Insurance to the Insurance Companies

  • Reducing the percentage of false claims
  • Regulating the cost of medical treatment
  • Easy to extract customer data, bills and illness related information to determine the final cost

TPA Insurance Companies List in India

  • Vipul MedCorp Insurance TPA Private Limited
  • Rothshield Healthcare TPA Services Limited
  • Medi Assist India TPA Pvt. Ltd
  • E-Meditek Insurance TPA Limited
  • Focus Health Insurance TPA Ltd
  • Family Health Plan Insurance TPA Limited
  • Dedicated Healthcare Services TPA (India) Private Limited
  • Ericson Insurance TPA Pvt. Ltd.
  • Vidal Health Insurance TPA Services
  • United Healthcare Parekh TPA Pvt. Ltd
  • Spurthi Meditech (TPA) Solutions Pvt Ltd
  • Raksha Health Insurance TPA
  • MD India Healthcare (TPA) Services (Pvt.) Ltd
  • Heritage Health TPA Pvt. Ltd.
  • Safeway TPA Services Pvt. Ltd
  • Sri Gokulam Health Services TPA (P) Ltd

 In a nutshell

Third-party administrators or TPAs play a major role in the health insurance industry. Whether it is the policyholder or the insurance provider, both need to contact TPA if any information is required regarding claims administration, enrollment, premium collection, etc. So, its mandatory to understand third party health insurance or TPAs role in health insurance.

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