TPA: Third-Party Administrator in Health Insurance

The recent ongoing pandemic has led us to realize the importance of better health insurance facilities to provide cover to our families. There is a need for better policies and more health care products to cater to the dynamic needs of the people. The existence of the various health care policies and offerings in the market are too many for the Insurance companies to keep track of on their own. This is why there arose the need for a Third Party Administrator.

According to IRDAI, a Third-Party Administrator (TPA) is a corporation that is registered with the Authority and is hired by an insurer to provide health services for a charge or by any other name that may be indicated in the health services agreement.

A Third Party Administer is an entity that helps in the processing of claims aspect of the insurance between the insurer and the policyholder along with providing cashless facilities.

Some aspects of the Third-Party Administrator can be summed up as follows.

? Serving as a link between the insurer and the insured after an intimation of a claim is made.

? Facilitating the approval and disbursal of claims.

? Maintaining proper customer databases.

? Provision of cashless hospitalization.

? Provision of value-added services.

? Provision of customer service.

? One TPA can be linked to various policyholders.

? Seamless and smooth claim settlement process.

Role of the Third Party Administrator (TPA) in Health Insurance ?‍?

The major role of the TPA is to deliver various administrative services on behalf of the Insurance Companies.  They ensure easy and smooth settlement of the claims process, providing crucial support to the Insurer. Here is a summary of the same.

• Connecting the Insurer and the Insured - Once a claim is made the Insured gets in touch either directly or indirectly with the TPA. The role of the TPA is to provide the unique identification number to the patient which helps in starting the process of a claims settlement.
• Issuing Health Cards to the insured - A validation procedure is carried out on every policy given to the policyholder. It is performed by the issuance of a valid health card. This card contains information about the policy number as well as the TPA in charge of claims processing. The insured can provide this card at the time of admission to the hospital and notify the insurer or TPA of the claim's occurrence. It's one of the most important documents for the claim processing.
• Maintenance of records - The TPA is responsible for maintaining all relevant records about the patient. All crucial information is stored in proper databases by the TPA.
• Expediting the Claims and Settlement process - A TPA is responsible for expediting the claim as soon as the insured informs them of it. Their task is to go over all of the documents that have been submitted in support of the claim. It can request as much information as is required to double-check the details. The claim will be settled either cashless or on a reimbursement basis. In any scenario, a TPA will be responsible for inspecting all documents. The TPA can acquire the documentation from the hospital in the case of Cashless. In other circumstances, the TPA may request the policyholder's supporting documents and bills.
• Provision of value-added services - Along with processing the claims settlement, the role of the TPA also includes arranging other value-added services for the Insured such as ambulance services, wellness programs, and the like.

Provision of Helpline Facilities ☎️

The insured can avail all information as well as other assistance related to their Claims by calling their TPA’s. This facility is available as customer service numbers that can be called from anywhere.

Building a Strong Network of Hospitals ?

TPA also analyses whether the hospitals fit the standards for being part of the network hospital chain, and may provide the policyholder additional services such as ambulances, extra beds, medicine supply, and so on.

It also establishes a solid network of hospitals where policyholders can receive care. The TPA aims to enlist the top hospitals that can swiftly set up cashless payments and allow for fee negotiation. 

When it comes to taking group health insurance for your team, understanding the role of TPA comes in handy. A cashless policy reduces the financial stress on your employee in times of medical emergencies.

To make group policies even more lucrative for you and your employee, get an estimate from Plum Insurance.

The following are some of the advantages of using Plum Insurance.

• Employers may access all of the required information from a dashboard and make appropriate changes as needed.
• Chat-based support: Plum offers a claim submission service via WhatsApp, which greatly improves the overall usefulness.
• Employers have more flexibility with the Plum dashboard because it can be accessed from any device.

While choosing the health plan for your employee, remember to make it more efficient through cashless facilities and a broader hospital network.

This will help employees to save time and avail efficient treatment facilities at varied centers. To avail the features like guided claims, 24/7 customer support, and a simplistic approach to a health plan, talk to the experts at Plum and unlock the enriching health insurance experience.

FAQs

What is the role of a third party administrator (TPA) in health care?

The role of a third-party administrator is to serve as a link between the insurer and the insured.

What does third party responsibility mean?

Third-party responsibility refers to the legal obligation of the entity to pay part or total of the expenditure incurred for the medical assistance rendered.

Why do insurance companies use third-party administrators?

Third-Party administrators are used to expediting the claims' settlement process for the insurance company.

What is the significance of a TPA number?

The TPA provides a Unique Identification Number to the insured, which helps in the claims' settlement.

FAQ

Q. How does a policyholder choose or change their Third-Party Administrator (TPA)?

A. Policyholders often rely on their insurance company to assign a TPA. However, some insurers may allow you to select or change your TPA at renewal. This choice depends on the insurer's policies and the agreements they have with various TPAs. If you're considering a change, contacting your insurance provider directly is best. They can guide you through the process and any options available.

Q. What are the specific criteria used by TPAs to evaluate and enlist hospitals into their network?

A. TPAs evaluate hospitals based on several criteria, including medical facilities, quality of care, accreditation status, and the availability of various specialties. They also consider feedback from policyholders and historical data on claim settlements with those hospitals. The aim is to ensure that policyholders have access to high-quality medical care across the network. Therefore, TPAs continuously monitor and update their hospital networks to meet policyholders' needs.

Q. How do TPAs handle disputes or disagreements between the insurer and the insured regarding claim settlements?

A. In case of disputes over claim settlements, TPAs act as mediators between the insurer and the insured. They review the claim details, policy terms, and any supporting documents to ensure a fair assessment. If the disagreement persists, policyholders can escalate the issue to the insurer's grievance redressal mechanism. Many TPAs also have customer service departments specifically designed to handle such issues, ensuring that policyholders receive clear communication and support throughout the dispute resolution process.