Good morning everyone. Today we are going to look at the TPA in healthcare insurance under the health insurance management. My name is Dr. Stokhanil Gadaway. I am from Symbiosis School of Open and Distance Education, a department of Symbiosis International University.
So let's look at TPA in health insurance. What is TPA? TPA stands for third-party administration. As a Thoroughbred State Administrator, the middlemen in chain of an integrated delivery system that bring all components of the healthcare delivery, such as physicians, hospitals, insured and insurers into a single entity.
Those of you who have attended my previous lecture on health insurance may be aware of all these terminologies. Please check out this previous presentation to understand the basic terminology related to health insurance. So as you understand TPA stands for Third Party Administrator which acts as a middleman in chain of this integrated delivery system where it integrated the system services from the physicians, hospitals, insured and insurer into a single entity. So basically how TPA works as an integrator? If you look at this particular diagram you can see there are three main corners.
One is a policyholder that is a person. second is the insurer company and third is a healthcare provider in health insurance services. Now TPA act as an integrator where it provides cashless treatment to the policyholders, it settles claims and payments with the healthcare providers and for the fee it actually gives up the benefits of the administrative work and provider network to the insurer company. Where insurance company provided policyholder with the insurance coverage, and get the insurance premium and the health policyholders get the services from the healthcare providers. So TPI come in the middle where it integrates all the services provided by the healthcare providers and the insurance company and click between the policyholders and healthcare providers and insurance company at once.
These are the list of the TPA registers in India. This list may have been reduced or may have been more TPAs added since I made it last time because it's a very dynamic sector. There have been recent changes in the policies related to TPA in India which actually lead to the merger of few major TPAs. So we have basic, we have big players like United Healthcare, Parekh TPA Private Limited, Mediasys India TPA Private Limited, MD India Healthcare TPA Services Limited, Paramount Health Services TPA Private Limited and E-Meditech TPA Services Limited and Raksha TPA Private Limited Services. These are the major player in India right now.
At least in western zone MD India, Raksha and Mediasys are the major player in as a TPA. Please look at this list. These are the TPA in the sector where most of the health insurance managers actually get their jobs. So now look at the working of a TPM. Please look at this particular diagram.
Here we have the insurance company in the middle, below that there is a third party administrator, there is a TPM. We have regulators which is IRDA. We have macroeconomical factors at right hand corner.
On the right hand bottom we have healthcare providers and left hand bottom we have policyholders. So as you understand that insurance regulators actually deals with the policyholders through the regulating the policy government terms. Regulators are actually affected by the macroeconomic factors which also affect the healthcare providers.
Healthcare providers actually provide the services to the policyholders and in due of that they actually get the reimbursement from the insurance company or third party administrator. Here the policyholders provide the premium to the insurance company and For the fees for the services, TPA actually combines the reimbursement for the healthcare providers and provide the healthcare providers network to the policyholder. So TPA here as I told you previously act as a middleman where for the fees of the services it gives the reimbursement of the healthcare providers and provide the services to the healthcare providers by linking healthcare providers with the policyholders. Please look at this.
particular diagram to understand the role of a TPA you know or working of a TPA in macroeconomical situation where macroeconomic factors actually affects the fees for services, affect the regulators and at the same time the regulators affect the policy holders and the macroeconomic situation vice versa. So what are the key services rendered by the TPA? TPA help in environment process Provider contracting and management.
Provider means healthcare providers. It actually has its own preferred provider network, PPN. It helps in claim processing, claim management and control, grievance rate management, investigation and fraud control, and customer service account management.
Basically, if you look at the services provided by the TPA, you look at the TPA helps in enrollment process. environment of the healthcare providers in the preferred provider network that is the PPM where they actually provide the contracting and management with services with the providers. It helps health insurance for claim processing and at the back end it actually helps in claim management and control with the healthcare providers.
Also whenever any grievance is filed related to the insurance health insurance that gives us re-advancement management system is taken care of this TPA and any investigation or fraud is investigated by the TPA where it investigates fraud from the side of the healthcare providers and insured person both. Then last is customer service and account management. These services are provided by the TPA. So you have to understand that here TPA as a third party administrator as a middleman. actually play a very vital role when it provides the services to the insurance company, which is similar to the outsourced services.
Then, actually what they do is they impanel the hospitals or healthcare providers. In this hospital, people can actually, the insured person can get the cashless claim. And if they go out of this PPM, they can actually have a claim processing system, where they can submit the document and this claim is processed by the TPA and Insurance company is actually provide some lump sum amount which is to the TPA for settlement of the claim and from that amount the claims of the claim of the insured person are settled by the TPA under the guidance from the insurance company. So this is how the TPA works.
So you have to understand whenever going to the hospital as a patient and you are admitted and you are asked for submitting the document, you are submitting your document to the TPA. So There are people in the hospital who are actually dealing with the claim processing and clashless processing and dealing with the TPAs. And in the TPA they have a claim department, they have a clashless department, then they have an investigation and fraud control department and administrative department. So basically what happened is if you are claiming for the already already consuming healthcare services and you are actually paid from the out-of-pocket expenditure then your claim goes to the claim department and according to terms and conditions of your insurance company the claims process by the TPA representative which is called as a claim processors.
This processor look at the every nitty-gritty of your health insurance policy and check whether whatever reimbursement is provided is according to that healthcare policy laws or not and they follow or not and then if you are actually going for a cashless cashless sorry if you are going for the cashless facility then make sure your claim goes to the classless department where the claim actually they they provided the estimate required for given surgery or any procedure and what exactly the expenditure they can pay from the in lieu of their insurance policy insurance policy and this cashless estimate in generally get the decision within 24 hours 12 to 24 hours so this is how the as an insured person you get interact with the tpm now you have to understand that tp have three different role role with the insurance company with the insured person and with the service provider that is healthcare service provider. So let's look at the role of a TPA with each one of these factors. First is role in terms of the insurer. What is the role in terms of insurer?
They carry out all administrative work of the insurance. So insurer as an insurance company, they carry out the administrative work of an insurance company. They manage the information and data about the claim processing, cashless facility. and the patient birth data MI assisting for the insurance company. They administer the claim through the claim administration and they standardize the treatment procedures.
TPA also helps in bringing down the consumer and providers moral hazard through monitoring and medical cost management. So basically what TPA do is, TPA standardize the rate for each and every treatment that they can reimburse and from that they can actually provide that what level of standard, what level of what level of service is or what level of standard, what kind of reimbursement they can provide or what kind of estimate they can provide for the cashless. By this way they can actually heavily involve in medical cost management. Then for insured person what exactly the TPA role played in terms of the insured person. So if you look at your medical insurance card you look at they are not issued by the insurance company as per but they are issued by your TPAs.
So we will have the logo, name, head office address, number and email id and 24 hour customer care number at the back along with your insurance number or members or your insurance id number on your insurance id card and this card is actually provided by the TPA. Now TPA already as I told you provide the 24 hour toll free line to inform in the case of the claim. It also arranges first day of a patient. in a hospital and most important is people negotiate with the services provided regarding quality of a care, credit facility, discount, package pricing, priority appointment and admissions. So all these things are negotiated with the service provider through the TPAs only.
PPA also facilitate the cashless and hassle free services at the hospital. So if you look at any hospital, when you go for a cashless claim, TPA provides the administrative services which make these cashless services hassle free and more efficient. Now the third that is role in terms of the service provider.
Here as a service provider, TPA has sent out the authorization letter to the hospital, reimburse the hospital for the treatment, provide more patients to the provider providers, Better management of a patient, help in designing, customizing the health plans, both for the groups, corporates and insurers. Provider the natural management that is contacting with providers in terms of the discount, quality, cashless facility, utilization review etc. And in a claim education where the documentation of the claim, eligibility of the claim, coverage and settlement of the claim process is taken care by the TPA. So to understand that wide range of services are provided by the TPA to the healthcare service providers. It actually sends the authorization letter for admission of any procedure for a hospital and then it actually remembers the hospital for the treatment expenses, provide more patient to the hospital because impanel hospital generally get the more patient because where they get the cashless they provide with the cashless facility.
which is preferred by most of the insured persons. Then in benefit management, help in designing customizing health plans both for the group corporates and the insurance. Then for network management, it actually gets the contact with the health providers. It also deals with the various discounts, various quality care management and utilization for the review. Then as a claim settlement party, third party claim settlement, It gives a claim education where TP actually get the to settle the eligibility of the claim, handle the documentation of the claim for the hospital and provide the coverage for the claim settlement process.
So there are three different roles, there are three different categories where roles of the TP are divided. First role with the insurance company, second with the insured person and third with the health services provider. Then TPHI have to submit some medical information system and reports to the insurance company on the regular basis. What are these insurance information?
Let's see. First, they have to provide the information for enrollment information of a patient. They have to provide the ID card status, how many ID cards are generated, how many are sent, how many are processed, how many are cancelled.
Then, pre-authorization status of each cashless facility. Then, claim and reimbursement analysis. how many claims are actually done, how many reimbursement are then, what is the ratio of insurance claim and reimbursement.
Then there is a claim float utilization report. The float amount here is amount which is given by the insurance company to the TPA which is a lump sum amount given by the TPA to the TPA by the insurance company where TPA managed to process the claim or set up the claims and cashless estimation. through this float amount.
So how much float or utilization float amount is utilized by the that report has to send by the TPA to the insurance company. Then what are the TPA fees available that statements is necessary and call center report office wise. Office wise call center report is very necessary because it's mandatory for TPA to provide 24 7 call center services for in case of the claim management or claim settlement. Now we have to look at the in network claim process. So first those who do not understand this particular terminology or for those specifically who do not who did not attend my previous lecture I have to tell them that in network claim process means there is a preferred providers network PPN is actually settled by each and every TPA where a TPA impanels the hospital under their network where they can actually have they can actually provide the cashless services.
So in in-network, the claim process is different at the in-network hospital and out-of-network hospitals. So here we are talking about the role of a TPA in in-network claim process where receipt and record of the data and member enrollment was done by the TPA, issuance of the photo ID card call center number was done by the TPA, mailing the network list and procedure. PA admission authorization is provided, even doctor's prescription, admission forms, information, health hospital information, all these things are checked by the claim settlers or claim insurer managers. Then claim for accompanies with original bills along with the doctor's prescription and diagnostic reports and discharge summary. Original bills are necessary with the original doctor's prescription and diagnostic report and discharge summary.
for the claim settlement. Then out of network claim process where I have to tell you out of preferred providers network there is no cashless facilities provided. You are insured to pay to the hospital and submit the following documents.
So TPA need following documents for out of network claim process where it requires the claim form, doctor's first prescription, original bills with the diagnosis and original discharge summary certificates. Now there is one exercise which is normally involved and which is the chief function of a TPA that is third party administration which is called as a cost containment measure because whatever the float amount is given by the insurance company it is actually mandated that most of the claims most or possible number of larger number of the possible possible enlargement of the claim should be settled by the TPA through this float amount. In in order to follow this mandate, TPA goes through some cost containment measures. First is they scrutinize the bill before release of the payment.
So now bills, medical bills are actually checked for the prescription, original prescription or against the discharge card. Any medicine which is actually not part of a discharge summary or doctor's prescription, that bill is not paid. Any Out of any bill item which is not related to medicine or not related to current admission is actually not paid by the TPA.
That particular amount is get deducted. Any consumables like diapers or scrape bandages. I think we have some problem with the network. Please be patient with me. Okay, so I will start again.
Cost containment measures where bill is scrutinized before the release of the payment where bill is checked whether only bill for the medicine or any bill item which is other than the medicine like consumables like diapers or the crave bandages is deducted from the bill and it is scrutinized before the raise of the payment. This continued rates eliminates the reimbursement fraud. Fraud is actually eliminated, reimbursement frauds are eliminated by the investigation and the fraud detection department where the representative of the TPA actually visit the healthcare facility and also interview the patient and check the validity of their claims and their illness. Then there is a medical procedure audit elimination of unnecessary prescription.
So medical procedure audit information means any extra prescription like prescription for unnecessary multivitamins, unnecessary items or food supplements or protein supplements are actually deleted during this medical procedure audit elimination process. where the bill for these protein supplements or food supplement items are deducted from the final bill is payment. Now we have to look at the regulation. The TPA before functioning or before started functioning, it have to fulfill some regulation or some laws.
The first is minimum paid up capital should be 5 crores. Minimum working capital should be 5 crores. Initially it was 1 crore but after the 2013 2013 improvement in the their legislation they actually go from 1 crore to the 5 crore.
At least one director qualified doctor registered with the MCI, TPA not to engage any other business rather than as a functioning as a TPA, then it should operate under the insurance company, service policy holders or insurance insurance behalf, It should range of provide the range of services restricted to the insurance contract only. It regulations provide the marketing. So TPA cannot do any kind of a marketing, any kind of advertising for its own sake. Provision of recovery and you must observe that you will not see any advertisement of any TPA in open market. Then there is a provision of recovery and penalty for the wrong settlement.
Then there are claim control measures have to be put out by the TPA and standardized billing system should be put out where adoption of the diagnostic and procedure code is a necessary thing. So generally what TPA do is, TPA adopted the international classification of disease and according to that they provided the standard code for diagnostics and procedures. Advantages, better quality standardized medical services. So what are the advantages of the TPA?
Due to the TPA, we can have a better quality standardized medical services to the policyholders. So as administrative part or outsourced as a third person, TPA actually enhance the quality and standard of medical services to the policyholder by standardizing the medical services. Claim cost management, contracting and discounts.
So basically what happened is cost management is very crucial and this cost is actually reduced due to outsourcing and contracting and discounting. Also, TPA provided the cashless facility which leads to the elimination of the cashless facility. of the operational difficulties, then it have a less problem to the employers, reduce the headache and administrative cost of the claim management to the insurance company and you will not believe TPA have a huge compilation of the health data which can be used for further analysis for the market purpose for the research purpose. We have to understand that due to TPA we have a better quality by standardizing the medical services then TPA actually do the claim cost management by contracting and discount providing discounts of the healthcare providers then it also provided the cashless facility and eliminate the operational difficulties it provided the less problem to the employers it also reduced an overhead and administrative cost of a claim management at the same time it is repository of the huge number of data health related data which can be used for the marketing or research work Now we are going to the drawbacks. So there are quite a few drawbacks.
Increased premium for policyholders. As I told you, instead of insurance company, if TPA is providing, it is going to charge some fee. So though TPA actually charges this fee to the insurance company, who is going to ultimately bear the load of this charges?
The insured person or policyholders are the ones who are going to pay. for this increased third party administration charges. That's why premiums are increased for the policyholders whenever there are TPAs or more.
Then the restriction in choice of providers, basically what happened is if I'm impounded by my policyholders to the certain TPA and TPA have this PPM preferred provider network, then I'm restricted to actually get my healthcare services from those hospitals only because I would prefer the cashless services. and for cashless services i have to go to the preferred provider network ppn for that particular tpa it actually reduce or restrict my choices for our healthcare providers then there's a risk of collision with the providers of course there's a risk of closure with the providers especially in the big city where there are a number of healthcare providers actually and they are actually practicing within proximity of each other then there's a high dependency on tpa can lead to certain hurt in insurance business if the agreement with TPA get closed. So basically what happened is in certain part of the country or certain part of the city or something like that certain demographics actually have a high number of insurance person from certain TPA it would give the high dependency on TPA and it can actually hurt the insurance business if agreement between the TPA and the policy or insurance for a person insurance insurance insurance company is ended then fraud by the tpa and the reputation of the reputation drama damage for the insurance as well so any fraud conducted by the tpa actually going to ruin whose image the insurance company's image so you have to understand that though tpa have its own department of the investigation and fraud detection it does not actually have all right to audit the TPS function. So it can happen that if TPS are building a reputation for the insurance company, the TPA can also ruin the reputation for the insurance company.
Less control over the claiming processing for the insurance can lead to the lower quality. So what happened is normally TPA have less control over over the control claim process. So insurance which can lead to the lower quality.
So less control over this claim process by the insurance company can actually lead to the TPA because TPA is the one who is going to handle all the claim processing services. So there is no control directly for the insurance company for the TPA in their day-to-day functioning. That's why there is no direct monitoring lead to less control and lower quality of a claim processing or claim settlements. Then the TPA has a lower incentive to in controlling the claim cost for insurance.
So the actual TPA have a very low incentives. Poor claim management can lead to higher certain cost and thus higher premiums. Example, poor unification, poor claim adjustment, etc. So basically what happened is, poor claim management can lead to the, if claim management, claim process management is poor, lead to the higher claim cost because it increases the claim processing cost and thus lead to the higher premium which is actually you know this burden of higher premium is actually shared by the or shared or by the policyholders only. Here they are given three examples like poor exam investigation and poor claim education which are the actual reasons why because these are the actual reasons of poor claim management.
by any TPA. So insurer is dependent on TPA providing good services to its customer as a TPA has a direct contact with customer then poor services for the TPA may harm the insurance reputation. So you have to understand is insurer is dependent on TPA because it would get the services only by the impairment panel which are actually part of the TPA's provider provider network.
So it depends. TPA for providing good services, its customer has a TPA as it has a direct contact with the customers and these poor services are actually going to help to TPA to ensure or to and it may harm the insurer's reputation. Then most of the time what happened is certain TPAs don't have or don't have negotiation power with the certain healthcare providers. In Pune also we can have a certain big. Old hospitals are not part of any preferred providers network of the major TPAs.
So why it happened? Because there is no negotiation power with the hospital. The hospital is very good and very old and they have steady patient flow.
In that case, what lead is networking become get weak. There are very few hospitals which are actually accessible to the insurance holder because there is very few hospitals in preferred providers network. So this can lead to the weak hospital networking and actually affect the reputation of a TPA and the insurance company itself. So after looking at all these things at end I have to ask you what are the benefits TPA get from the insurer?
What do you think? First is instead of third party administrator it will become very cost saving because insurance company cannot indulge. into the claim settlement claim management process. So by adding or outsourcing their work they actually have the cost saving they save the cost and which direct benefit get to the policyholder.
Then it can insurance company can provide the better services to the policyholder because tp as a third party administrator can actually claim process the claim faster and TPA is the one who provides the cashless facility. That's why TPA or engaging the TPA are more beneficial for the insurance company. Insurance company now can focus on more of its core tasks like distribution, underwriting, business strategies of the insurance company.
So what happened is insurer can focus more on the core tasks now that the day-to-day cleaning or settlements or cashless facility settlements actually taken care by the TPAs. Then brand reputation on entry level is highly dependent for the insurance company and it is actually based for insurance company on which TPA they are having connection with. Then there is control of a possible fraud by private healthcare providers. Why?
Because TPA has investigation and fraud department where they have people who are trained in fraud detection and they visit these healthcare services facilities and actually get the treatment part down. So we have a control process for possible detection of fraud by providing private healthcare providers. Then TPA helps insurers in analyzing the data.
As I told you previously, this healthcare data is available to the TPA in a huge amount. So this data can actually be used for market analysis or for research purposes. So TPA can actually help insurance companies to analyze this data so insurance company can come up with a better product can actually have a better underwriting and actually adapt to better business strategies to spread their presence in the market so you can understand how the this having a tpa is actually beneficial for the insurance company or insurer now we have to look at the changing role of the tpa in healthcare insurance industry As I told you previously that after the 2030 health regulations by the IIDI, there is a massive change in the role of a TPA.
What happened is after the regulation, it is mandatory that every claim has to be approved by the insurer, that is insurance company, and paid by the insurer. No direct hospital agreement by the TPA. TPA cannot get direct engagement with the hospital.
Insurance company should settle to settle down the fees for the TPA with that particular hospital. whole environment process to be carried out by the insurer. So what happened is environment or impanelment of the patient into their product or insurance product is now the bonus of that is now on insurance company. So as an insurance company they should reach out to the banks, they should reach out to the customers and they actually should have some understanding okay that how this TPA is going to benefit them and that's why this regulation changes and put the owners of the environment of the process on the instrument.
In the most recent draft regulation, the working capital requirement has been increased from 1 crore to the 5 crores. As I told you that minimum capital requirement currently working capital requirement for any TPA is 5 crores. This 5 crores actually increased from 1 to 5 crores in 2013. Then introduction of the new TPA of India owned by non-life insurance PSU would mean that all PSU business moving from existing TPA.
to this one TPA. So what happened is there is an introduction of a new TPA and which is owned by the non-life insurance Psu sector. So what happened is the whole insurance sector is actually divided into as you understand very rightly that it has life insurance, it has non-life insurance, I have general insurance and healthcare insurance is a part of general insurance okay so which is a part of non-life insurance Psu. So you have to understand that now the role of a TPA is changing in India. TPA is one of the sector or one of the segment in health insurance where most of the job for health insurance management are there.
You have to understand the role of a TPA, the working of a TPA and what are the process or how the TPA work actually work out. What are the disadvantage? What are the advantage or drawbacks of the having TPA? How actually TPA benefit the insurer?
And what are the how the role of a TPA is actually changing throughout the time in this past few years? I hope you understand all these things and question we can have a chat and you can put your question in chat box. I'm very happy to answer your answer your questions. OK, thank you very much.
Okay, there is an anonymous question first. Who is the list of in network hospital issue 2? So network hospital list is provided to the insured person.
Whenever you purchase the policy, you get the card and along with the card, you will also get the booklet where the list of the network hospital is provided to the policyholders. Or you can actually go into the website of the TPA and you can download the PDF which contains the list of the network hospital. I hope I answered your question. Another is, please explain out of network process again.
Okay, so basically what happened is out of network means there are the hospital or healthcare facilities which are not part of the preferred provider network. Now these are the hospitals which are not part of a network of a TPA and these are the facilities where you cannot get the cash cash facility. So while processing your claim in those facility you have to fulfill different set of the document then then of the different set of the documents which are claim form sorry claim form doctor's first prescription original with the diagnostic report discharge and summary certificate where in in network claim process you actually have the id card which you can show you can have the pre-admission authorization and along with that you have to submit the hospital information admission form claim form accompanied with the original bills doctor prescription diagnostic report and research summary and in network claim process you can actually adapt for the cashless facility also i have i understand i given satisfactory answer to and explain the out of network process what are the difference in role of the tpa and health resources company so as i told you you have to understand that here tpa is come in the middle where with insurance company TPA charges some fees for their administrative procedure or outsourced processes and third party administration actually create a network with the healthcare providers by which policyholders are actually get the healthcare services.
So insurance company do not provide directly contact with the healthcare providers it is attached with the healthcare providers through the TPA and insurance company is attached with the policyholder because they issue the policy and get the policy premium from the policyholder. So third party administrator actually settle the claims between the healthcare providers, give the payments to the healthcare providers. These are not given by the insurance company and provide the cashless facility to the policyholders, which is also again not provided by the insurance company. So basically there is a question by the Jyotishri why there is a need for TPA to operate under the health insurance companies only. So Jyotishri actually the thing is TPAs are exclusively worked for the health insurance companies because they have a complex set of mechanism.
In any another non-life insurance or life insurance there is no third party which provide the services. For example I am giving you the life insurance company where the life insurance company you get them lump sum amount in case of the death of the policy holder so there is no third party involved but this in particular case you have three different parties one is insurance company second is a tpa sorry second is second is a policy holder and third is a healthcare providers so to coordinate between these two parties insurance company should have to engage in massive administrative process and have to invest in resources for the administrative processes So to our infrastructure so how to avoid that they adopted this process where they can engage with the TPA and now TPA can actually deal with the policyholder for providing the cashless facility and deals with the TPA and have the network of the TPA. Understand I hope I give the satisfactory answer to your question.
Then another question by the Jyotishri. Can an insurance company work without TPA? Of course it can work.
but then again they have to provide or they have to come up with the massive infrastructure of administration. So we have to understand in a country like India which is a big country, we have thousands and lakhs of the hospitals, how insurance companies are going to deal with day-to-day cashless facility estimates and claim settlement with all these hospitals. That's where the TPA comes and that's why the environment of the TPA is very crucial when it comes to the health insurance.
I hope I give you a satisfactory answer to your question, Jyotishree. And it's really nice to see the very active involvement from you people. Then there's a question by the Kamira.
Hello Kamira, welcome back. It's nice to see that you are actually attending lecture again. What is the underwriting means?
Of course, the underwriting is a very different issue. The underwriting is something you will get to see or get to understand in detail in the future with the insurance exports. That is right now out of the scope for this particular lecture.
There is a question by Dr. Inshabung Beg. Dr. Inshabung Beg said that can you please share the lecture LMS. So basically we are now in the process we are actually going to share the lecture and people at least ppt with you in future but for the lecture you have to wait for some time.
There is a question by the okay. Question by Dr Sonal Chinchay. Please show the slide of advantages of the TPA. Okay, so basically there are a few advantages where due to the TPA we can have a cashless facility. Okay, we have a better quality of standardized medical services due to the TPA and basically TPA have a claim cost management by contracting and discounts.
And TPA have a huge compilation of the health data which can be used for marketing and healthcare research. Also, TPA reduces the overhead and administrative costs of the claim management which actually lead to the less policy fee. Then we have less problem to the employers because the process of the claim settlement gets smooth because of the TPA. So if you understand that major advantages are they provide the clutchless facility, they provide the claim list, they actually may reduce the cost of the claim management, they are responsible for the betterment of the quality by the standardization of the medical services to the policyholder and they have a huge compilation of the data which can use for the marketing and healthcare research. I hope I explained your query Dr Sonal Chinche.
Then there is another question by Dr. Sonal Chinche. Please explain float utilization report. So basically float utilization report is a report which is sent by the TPA to the insurance company.
So what is this? This is a float amount generally and this particular float amount is actually This particular float amount is actually settled by the, this float amount is given by the insurance company to the TPA to settlement the claim. An insurance company now asks for the report that how many claims are settled and how many amount is actually utilized from this float amount which is given by the insurance company.
company to the TPA. So there is someone who is anonymous who is actually saying I am not understanding well. Can you please tell me in detail what exactly you are what topic you are not understand well then I can help you with the understanding make you I can help you with that particular topic I can.
again explain that particular topic please show the first slide again please show that i already explained the advantages of the tpa so i think if you need i can again show the first slide so what is the difference between the tp and insurance company i'm afraid i already explained the difference between the tp and insurance company where i actually mentioned And if you look at the figure which explain the working of the TPA, it can actually show where the insurance company stand and TPA stand as far as this particular environment is concerned. So there is not a query but request from Dr. Kamal. Please put all the videos on portal.
If some part is missed, we can listen again. Okay. Actually, as I told you, we can actually share the PPDs with you in very short. But for the lecture, you have to wait for some time. But eventually it will be loaded on the system and the link will be shared with you.
There is one statement by Anonymous. Now some insurance in-house TPA. Yes, of course.
Basically, some insurance companies have their in-house TPAs. This is how they actually deal with the administration. cost of the administrative cost. So there is a question by the camera again. Policyholders are dealing with only TPA.
Come in. So as far as the issuing of the policy and claiming and giving them insurance or purchasing the policy, policyholders are actually dealing with the insurance company, but For the cashless facility for the claiming facility now they have to deal with the TPA. So there are two instances, there are two parts.
One part is purchasing the policy and giving payment for that policy which is policy order deal with the insurance company and here after that when we have anything any claim or we have to avail the cashless facility and that time policyholders have to deal with the TPA. There is one question by the the main work of the TPA while claim. So as I told you, the work of the TPA is providing the ID, giving the report, providing the cashless facility, do the claim settlements. So basically I will explain to you. OK, so you are you wanted to admit for certain surgery.
First you get the note from the surgeon saying that. you are necessary diagnosed with certain condition and this is the surgery you want to go with now you have that letter you have your insurance policy you have an id card now you go check out the list of the hospitals you go to the panel hospital you go there and you give these documents now they will give you the admission form they will give you the claim insurance form and you have to fill out the information and then all this information will go to the tpa now tpa will look at your policy how much your policy is what will be the cost of the surgery And they will provide estimate to the hospital that out of this particular surgery this is the estimate that this is the maximum amount we can pay. OK, and then hospital will contact with you and they say that your claim is in process already estimated they will provide this much amount and this much will be paid by you something like that and after that you will get admitted and then you will have your surgery cashless and after paying the rest of the amount that is copayment you can go home. So this is how TPA actually work.
In case of the claim, you already go into the hospital, you provide the out of pocket fees and now you get all the documents ready. You have your bills, you have your discharge card, you have your admission card, you have your doctor's prescriptions. Now you combine all these things, attach bills with them and then along with your policy and the claim form, you submit it to the TPA. Now TPA will process that and according to them issues, policy terms and conditions, they will release the one amount which will be the part of your claim settlement. You understand?
Now I think you understand what exactly that how exactly TPA work in two different scenarios. Who manages the passing of the claim? So basically there is a claim settlement team inside the TPA.
There are the people who are actually trained for the claim settlement who settle them or who actually process the claim in the TPA. Approving the claim same team. So basically the claim settlement team is who is the one who approving the claims. So there is a question again by the Jyotish. Are TPA also operate with medical?
No, they are not operate with the medical. Basically they exclusively deal with the health care. So only part where they actually concerned with the medical is if you are purchasing some medicine from the medical, you have to have the prescription for those medicine. and you have to have the bill for that medical. Now these bills are checked with the prescription and any non-prescribed item, any additional item which is a food supplement, protein supplement, it actually gets deleted from the bill and that is settled.
Which TPA is the best? So I'm afraid that is nothing like a best TPA but right now MD India and Mediasys, Rakshas are one of the major players and Pyramid was one of the major players in the TPA. Are TPAs also operated with the medical company?
So basically Jyotishji please understand that medical is actually operated with some have in-house TPAs so they can operate with and within medical companies sometimes. So these insurance companies have tie-ups with one or more TPAs to provide services to their insured person or policyholders. Another question by the Anand Misra.
please explain the flow of approving the claim does it go to the insurance also so as i already i think i'll explain how the claim processing goes so basically you start with your claim document you have your discharge summary you have your medical bills you have your prescription by the doctors and you have bill from the medical all these things you have collected you can attach the insurance document you attach the claim form you submit it to the tpa then tpa will scrutinize according to the insurance term and policies and they will settle your claim. I think I understand, I am answer satisfactorily to your question Anand Mishra. There is a comment by the Jasmit Kaur, sir you have explained very well about to be thank you very much. It's actually been encouraging to get these comments like this from you.
Anonymous, what is in-house TPA? So in-house TPA is a TPA which are actually working under the insurance company. How the TPA confirm the quality of the care? So basically what TPA do is, this is again question by the Kamira, thank you very much for such a good environment and interaction with us Kamira.
So how does the TPA confirm the quality care? So basically what happened is, what TPA do is they engage with the hospital or healthcare providers and they establish the certain, if you provide this A, B, C, D kind of services, you are actually eligible for this amount of the claim. If you are providing only this and this, then your estimate for the particular surgery or particular admission will be reduced.
So, hospitals and healthcare facilities are actually claiming to get more and more from the TPA. They actually improve the quality of their care and try to involve more and more criteria for that particular surgery so they can claim for more amount. This is how TPA confirms the quality care.
Thank you sir, thank you. Jyotish is also saying thank you, thank you very much. I think we have last three minutes but I will try to answer as much as question possible. You can actually mail your questions, I will be more than happy to answer your questions.
Now there is anonymous question by the anonymous, what is the importance of today's topic for medical legal consultant? I am afraid as a medical legal consultant you will get many Many many many legal legal claims or legal cases where you have to deal with the frauds related to insurance company fraud or maybe where the policyholders are not actually satisfied with the services of the TPA and they are actually trying to file the case or complaints against the TPA. In that scenario, I think it is very necessary for medical legal consultant to understand whole working scenario of the healthcare insurance company. So Krishna Sharma, yeah, this is very good question. So basically it's not a commission.
It is a fee which is charged by the TPA and paid by the insurance company. Anand Mishra, is insurer anyway involved in claim settlement? No, sadly insurer person is not involved in claim settlement anyway. But if he's unhappy, he can file first complaint with the TPA. If he's unhappy, second complaint he can actually accelerate with the insurance company.
Then again, he's not happy, he can actually go. with the IRD also. Company is actually TPA who can work with more than one insurance company.
There is another question by Anonymous. What is the main work of a TPA while claiming? I already answered this question. There is a question by the camera.
Can't patients claim the full charges? Yes, of course, they can claim the full charges. But the problem is there is always some reduction done by the TPA.
So anonymous, how do I choose the TPA? So basically, TPA is assigned to you by your insurance company when you adopt the insurance policy. If you're not happy with the TPA, you can actually fill the form and you can change the TPA. Dr Divya Agarwal, thank you very much for your comment. Then Anandam, thank you for educating us.
Thank you very much again. Priyanka Gupta saying thank you. Sonal Vas is also saying thank you. Thank you Sonal, thank you Priyanka, thank you Divya, thank you Kameera, thank you Anand. I think you understand the function of the TPA very well.
If you have any question, I will be more than happy to answer your question. Anytime you can mail me. You can get my email ID from our website.
OK, I think it's time to say goodbye. OK, goodbye and have a nice day.