What Is The Role Of A Third Party Administrator or TPA In Health Insurance?

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What Is The Role Of A TPA In Health Insurance?

·         These are basically outsourced by the health insurance companies. They function as an intermediary between the hospitals where patients or policy holders undergo treatment and the insurance company .

·         These companies are licensed by the IRDA and have telecom facilities with phone numbers starting from 1600 which are toll free.

·         A Computer Database having all the details of policy holders.

·         Medical specialists to assess whether health care is needed or not, assessing hospitalization treatment and passing of the claim bills.

·         They coordinate with hospitals with respect to treatment of patients, settling of medical bills on behalf of the insurance company.

·         When a patient is ill he is not able to help himself. His relatives and family members admit him to the hospital and then have to apprise the TPA of the situation over phone or in writing. You have to specify the name of the policy holder, Policy No, ID Number, Name of the Doctor sent for treatment, Hospital where the patient is hospitalized, reason for hospitalization, Copy of the prescription of the Doctor.

·         All of this needs to be faxed so that the TPA can make a real time decision.

·         If the hospital where the hospitalization of the patient is going on is on the approved list then the hospital conducts treatment and sends the bills to the Third Party Agent. This is a case of cashless treatment.

·         If the hospital is not on the approved list , the treatment is conducted at the hospital. The patient pays the medical bills himself .Once the treatment is over the bills are sent for approval to the TPA's. Once approved the amount spent by the patient is refunded by the TPA.

·         Under the 5% concept the policy holder pays 5% of the hospital bills and the rest of the amount is paid by the TPA. There are certain expenses or components of the hospital bill which are not payable by the insurance company. In case all the components of the hospital bill are covered under the claims clauses of the insurer the 5% amount is refunded.

·         The charges of the TPA are included in the premium amounts charged by the insurer. In some cases discounts are given up to an amount of 5% if you opt for direct submission of bills to the insurance company.

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