Categorized | Health Insurance

how tpas function?

The Third Party Administrators (TPAs) are IRDA-acknowledged companies that provide Mediclaim services, such as Claim settlement, implementation of cashless service, database maintenance of the policyholders, and value-added tasks that an insurance company is not able to do due to the immense task and the infrastructure required for the purpose. In short, TPAs in India has become an essential service provider whose services are outsourced by the insurance company to implement Health Insurance benefits and claims efficiently and quickly.
 
In a scenario where there has been a sudden uncontrolled expansion in the insurance sector, especially the health insurance sector, TPAs help to implement the insurance claims in a planned way. They review records, keep the database updated and correct, interact with the families of the claimants on behalf of the insurance company regarding their health insurance Policy and the benefits that are due to them, and reimburse bills that are due. In other words, they streamline the tasks of implementing a health insurance policy.
 
Let’s check out how TPAs function and importance of their role in the insurance sector.
 
Organizing Emergency Treatments

The IRDA-licensed TPA is the service provider of an insurance company that has a legal authority to provide an ID for each Insured person on behalf of the insurance company. During an emergency, this card is used to locate the ideal hospital approved by the TPA with greater infrastructure and a panel of doctors for treatment. The hospital admits the patient on behalf of the ID card issued by the TPA.
 
The cost for the treatment is furnished by the TPA who is paid directly by the insurance company. The payment is either paid directly by the TPA to the hospital or the medical bills and miscellaneous expenses incurred in the emergency Hospitalization are paid by the patient to the hospital and later reimbursed by the TPA based on the health insurance policy of the patient. The TPA does not charge anything from the insured person or the patient.
 
Once the patient requires an emergency treatment, the TPA is notified about the same. The details of the emergency, such as the name of the patient, Mediclaim policy number, ID card number, and reasons for the emergency are provided by the patient to get the reimbursement. TPA monitors the entire process and the progress of the treatment. It also keeps a tab on the claim and the amount that can be disbursed as per the health insurance policy of the patient.
 
Mobilizing Planned Treatments

Planned treatment is financed by the TPA if the concerned hospital is listed among the TPA approved hospitals. The bills and other hospital charges are reimbursed by the TPA, making the process, a cashless one. If however, the hospital is not recognized by the TPA, it can still approve the same. However, the patient has to pay the bills and later get them reimbursed by the TPA.
 
Settling Claims and Assistance to Customers

Once a Mediclaim policy has been purchased, the records of the Policyholder and the policy criteria are passed on to the TPA. The insured person would now interact with the TPA and not the insurance company. From maintaining the database of insurers and their policy details to providing medicines, arranging ambulance services, and helping the Insurer get specialized medical consultation and treatment, the TPA provides all possible assistance to the policyholder.
 
TPA is a liaison operator between the insurance company and the insurer. It helps to mobilize better workmanship in the health sector so that the policyholder can get his or her dues efficiently through quick claim settlement, value-added service, and regularity in the treatment process.