Handling the nitty-gritty of health insurance can be difficult for an insurer, especially when dealing with high claims and payments. As a result, they are often burdened with repetitive insurance functions instead of focusing on core operations. The insured party, on the other hand, also expects 24/7 customer service and immediate help during emergencies.
A third-party administrator or TPA simplifies these issues. It helps insurance providers streamline their operations and ensures superior service to the insured.
In this blog, we’ll explain the importance and role of TPA in health insurance and how they streamline the insurance process.
What is a third-party administrator?
A third-party administrator (TPA) is an intermediary between insurance providers and policyholders. It is licensed by India’s Insurance Regulatory and Development Authority (IRDA).
Insurance firms typically outsource claim settlement to TPAs to streamline the process and decrease the overall load of processing claims. TPAs also offer other services, like premium collection, claims processing, customer assistance, policy administration, data management, and provider network management.
On the other hand, it is also beneficial for the insured as it streamlines communication channels while providing value-added services, like arranging for an ambulance, 24/7 customer helpline service, etc., during medical emergencies. Moreover, they ensure claims are settled accurately and comply with policy terms and conditions.
Role of TPAs in health insurance
TPAs are essential in managing different facets of health insurance. They-
#1. Maintain all important policyholder records safely and systematically. This ensures no time is wasted on gathering important documents while processing the claim.
#2. Ensure that the claims requested by policyholders are processed in a hassle-free manner. They can contact the TPA, and their payments will be made on time.
#3. Supervise their specific network hospitals to ensure they meet the required quality criteria and compliances. This helps simplify the claim settlement process.
How does a TPA work?
The TPAs work just as an intermediary does. The process begins with the insurance company appointing a good health insurance TPA to efficiently handle their claim processing and settlements.
Once appointed, the insurance company gives them access to all the important data and records required to deliver their services.
Then, when a policyholder requests a claim, the TPA connects them to their network hospital. They authorise the hospital for cashless treatment and settle the bill after proper verification and documentation.
If the insured opts for a non-network hospital, the TPA ensures the claim is settled on a reimbursement basis. In this situation, the insured has to submit all the medical bills and necessary documents to the TPA, which reimburses them upon receiving and verifying the documents.
Irrespective of cashless or reimbursed claims, the TPA sends all the bills and documents to the insurance company, which reimburses them for the amount.
How TPAs in health insurance help the policyholders?
TPAs use their expertise and resources to enhance the insurance experience of policyholders. Here’s how:
#1. Streamlining cashless claim facilities
The TPA makes it easier for the insured to receive a cashless claim facility. However, this is only applicable when they opt for a network hospital.
In this case, the TPA authorises the hospital for cashless treatment. They collect the required records and documents and settle the bill directly with the hospital.
#2. Maintaining records
TPAs maintain all records and paperwork of a policyholder’s insurance policy. This systematic documentation is critical for the claim settlement process.
It helps pass and verify the necessary information when the insured submits a reimbursement or cashless claim to a network hospital.
#3. 24/7 availability
Offering 24/7 customer service is crucial for a health insurance provider. A medical emergency can knock anytime, and the insurance company should be available to help the customer. This is where the TPA comes in.
Health insurance TPA companies provide this added benefit of being available 24/7 to assist the insured individual in every way.
The TPAs are on their toes to answer the doubts or queries of policyholders so the insured can reap the benefits of the insurance seamlessly and on time.
#4. Expediting the claim settlement process
During a medical emergency, insurance money acts as a valuable asset. And receiving it on time helps the policyholder handle the situation effortlessly. But how can an insurance provider ensure that the settlement is done on time? It is through the TPAs.
TPAs are equipped to handle multiple things, like connecting with the hospital and providing timely information and documents to the insurance company. This enhances the insurance provider’s service quality while reducing the claim and payment processing time.
#5. Providing value-added services
While timely access to insurance funds is critical during a medical emergency, it is not the only requirement. An insured person could also use assistance with calling an ambulance, the hospitalisation process, etc. TPAs provide these services, among others, to the policyholders as part of their value-added service. This includes:
#1. specialised consultations
#2. ambulance services
#3. medical supplies
#4. wellness programs
#5. lifestyle management
#6. 24-hour toll-free helplines
However, these services are offered based on the policy terms.
List of health insurance TPAs
There are multiple health insurance TPA companiesoperating in India. Some popular TPAs are-
#1. E-Meditek Insurance (TPA) Services Limited
#2. Medi Assist India TPA Private Limited
#3. Paramount Health Services & Insurance TPA Private Limited
#4. MD India Healthcare (TPA) Services Private Limited
#5. United Health Care Parekh Insurance TPA Private Limited
#6. Family Health Plan Insurance TPA Limited
To wrap up
With the growing demand for health insurance, the role of TPAs cannot be emphasised enough. The best TPAs for health insurance help streamline the payment process, provide value-added services to the policyholders, help maintain proper records of claims, and act as a bridge between the insurer and the insured.
With Tata Capital, you can access quality health insurance services across the country. Additionally, with our hassle-free online process, you can purchase individual, family, senior citizen, critical illness, or group health insurance in 3 simple steps. Visit our website to know more.
04 July 2023
5 mins read
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